實支實付醫療費用保險於複保險之適用探討

我國目前關於實支實付醫療費用保險的處理方式，因應主管機關於「人身保險商品審查應注意事項」及「人身保險要保書示範內容及注意事項」的規定，如果投保時要保人/被保險人已經告知投保有其他保險公司實支實付醫療費用保險，而該公司仍接受承保者，則應接受收據副本理賠。此一行政規定實施後造成重複投保不當得利之案件層出不窮，不僅扭曲保險損失填補本質、造成不良社會風氣更損及其他善良保戶之權益，本文針對此一現象，從實支實付醫療費用保險之保險原理出發，說明損失填補原則，以及與定額保險之差異，並引據法院實務判決說明實支實付醫療費用保險並不適用於大法官釋字第576號解釋之論述，認為雖然實支實付醫療費用保險雖然歸屬於人身保險之健康保險及傷害保險中，但性質在於填補被保險人因為保險事故所支出之醫療費用，所以仍有填補財產損失之性質，應有複保險之適用。準此，則主管機關所制定之前述行政規定，要求重複理賠情形，不僅違反保險原理，造成不當得利，亦有牴觸法律位階之情形，故本文研究建議針對保險法及前述行政規定進行相關條文修改建議。

關鍵字

實支實付；醫療費用保險；複保險；損失填補

並列摘要

In Taiwan, a full medical expense reimbursement insurance is currently regulated in accordance with the provisions prescribed in the Directions for the Reviewing of Life Insurance Products and in the Templates and Directions for Life Insurance Contracts. In the event that an insured (policyholder) has informed the insurer that he/she has purchased a full medical expense reimbursement insurance plan from another insurance company, and the insurer still sold an insurance product to the insured, the insured shall be entitled to an insurance claim provided that the insured submits a copy of the purchase receipt. Following the enactment of this administrative regulation, cases of unjust enrichment through double insurances emerged, which not only distorted the principle of insurance indemnity, but also engendered bad social customs and damaged the rights and interests of other policyholders. In light of this phenomenon, this study attempts to elucidate the principle of indemnity according to the concept of a full medical expense reimbursement insurance, and describe the difference between a full medical expense reimbursement insurance and a fixed-sum insurance. Furthermore, based on practical court cases, this study provides a discourse, asserting that the explanations afforded in the Judicial Yuan Interpretation No. 576 are not applicable to the full medical expense reimbursement insurance. Although the full medical expense reimbursement insurance is categorized as health and personal injury insurances in life insurance packages, its function is to indemnify the medical expenses incurred to the insured person as a result of personal accidents. Therefore, a full medical expense reimbursement insurance still indemnifies financial property losses and therefore should be applicable in a case of double insurance. Therefore, the aforementioned administrative regulation regarding repeated claims not only violates the principle of an insurance system, thus causing unjust enrichment, but also contravenes the legal hierarchy. Thus, this study suggests that the provisions prescribed in the Insurance Act and the aforementioned administrative regulation should be amended.