商業健康保險手術醫療保險金給付糾紛之研究

A Study of Surgery and Medical Insurance Payout Disputes in Commercial Health Insurance

李俊德(Jun-De Li)

指導教授 ： 蘇文斌

朝陽科技大學/管理學院/保險金融管理系/碩士(2010年)

摘要

隨著投保率不斷的提高，保險知識的逐漸普及，還有消費者意識的日益抬頭，被保險人對於自我權益更加重視。依據行政院金融監督管理委員會公布之統計資料98年度人身保險業申訴件數3,759件，較97年度3,180件增加579件，其中人身保險理賠申訴件數增加較多，並達456件。
現代醫療技術日新月異，許多侵入性手術已逐漸發展為較小範圍的微創手術或雷射或超音波或電燒或放射線…等其他治療方式可以替代，而對該疾病同樣可以達到治療的效果。對於因為科技的進步而發展出新的手術或治療方式而取代傳統外科手術者，常有無法獲得手術醫療保險金理賠給付，或以較低之手術等級，或較少之手術醫療保險金給付，進而產生理賠糾紛與爭議。
期盼透過合理期待原則的應用來減少商業健康保險理賠的糾紛與爭議，回歸保險制度損害賠償的原意，做有利於大多數被保險人之解釋，且符合不同時代背景與科技發展之進步之考量，以達到大多數人的合理期待。期能降低保險理賠的糾紛與爭議，使被保險人能獲得應有的理賠給付，且能減輕理賠人員的工作壓力，維護保險公司的良好形象，並實現保險制度的真諦。

關鍵字

商業健康保險 ； 手術醫療保險金 ； 理賠糾紛 ； 合理期待原則

並列摘要

With the continued increase in insurance rates, popularization of insurance-related knowledge, and rising consumer awareness, the insured are placing more and more attention on self-interests protection. According to statistics published by Financial Supervisory Commission, Executive Yuan, there was a total of 3,759 life insurance appeal cases in 2009, an increase of 579 cases from the 3,180 cases received in 2008, of which the number of life insurance claim-related appeal cases showed a greater increase of 456 cases.
The fast-changing modern medical technology, many of the invasive surgical procedures have gradually developed into smaller-scale mini-invasive surgery, or have been replaced by laser, ultrasound, electrical burn, radiation, or other treatments with the same results. For the traditional surgery that have replaced by newly developed methods of treatment or surgery due to technological advances, one often can not obtain surgery and medical insurance payout, or only receives a lesser amount at a lower surgery tariff level, leading to claims disputes and controversy.
Hopefully through the application of the principle of reasonable expectation, the disputes and controversy in commercial health insurance claims can be reduced, and the original intent of the insurance system can be restored, thereby providing a satisfactory explanation to the majority of the insured. This will align with the consideration of different background setting and progress in technological development, and fulfill the reasonable expectations of most people. It is hoped that this will reduce insurance claims disputes and controversies, so that the insured can receive the claim payout he or she deserves. This will also alleviate the pressure of claims staff, maintain a good image for the insurance company, and realize the true meaning of the insurance system.

並列關鍵字

claims disputes ； surgery and medical insurance payout ； business health insurance ； Principle of reasonable expectation

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