我國癌症保險理賠爭議之研究

A Study on Claim Dispute Regarding Cancer Insurance in Taiwan Market

洪彰欣(Chang-Hsin Hung)

指導教授 ： 林麗銖

淡江大學/商學院/保險學系保險經營碩士在職專班/碩士(2008年)

https://doi.org/10.6846/TKU.2008.00764

摘要

近年來國人罹患癌症比率節節上升，且癌症患者存活率之提昇亦造成治療期間延長，而癌症治療過程漫長及醫療費用高漲，已使得癌症保險成為每人必備保單之一，然癌症保險條款之相關名詞、承保範圍等，均有因定義不明以致於產生理賠爭議。
本研究經由說明癌症病患治療需求及費用、檢視壽險公司核保與理賠作業規範、分析條款約定內容文字及探討實際理賠爭議案例等步驟，並彙整隱含爭議點之條款約定條文，以提供保險公司改進保單條款設計及理賠作業規定之客觀建議，期望保險公司能消弭與保戶間對癌症保險理賠之歧見，進而改善申訴率並提升其形象。
研究分析四種癌症保險理賠爭議類型個案，包括罹患癌症與否之爭議、癌症手術之爭議、癌症併發症之爭議及癌末安寧療護之爭議等，重點建議如下：
1.保險公司加強癌症保險之宣導，擴大普及率與保障額度。
2.組成醫療服務諮詢團隊，提供理賠爭議案件之醫學專業意見。
3.定期召開同業會議，商討理賠爭議解決與改善之方法。
4.研擬癌症保險示範條款，並將條款之文字內容統一規範。

關鍵字

癌症保險 ； 理賠爭議 ； 訴訟 ； 申訴

並列摘要

In recent years, our compatriots suffering from cancer rate rises successively. Increasing cancer patient of survival rate lengthen the treatment period. The cancer course of treatment is long and hospitalization cost runs high. The situation makes the cancer insurance become one of everybody's indispensable insurance policies. Because the relevant nouns of the cancer insurance clause and the insured coverage define fuzzily to cause the dispute happen.
The research offers the insurance company suggestion to improve policy clause design and the claim administration stipulation objectively by illustrating the treating demand and expenses of cancer patients, inspecting underwriting and claim administration norm of the life insurance company, analyzing the letters of appointed clause, discussing actual claim dispute case, and gathering the article of appointed clause that implies the dispute. Expect the insurance company which could eliminate different interpretations of cancer insurance claim result with the policyholder to improve complaint ratio and promote its image.
The research analyzes four types of cancer insurance claim dispute cases, including the definition dispute of suffering cancer, cancer operation, complication and cancer peaceful treatment. The main suggestion is as follows:
1.The insurance company strengthens the propagating of cancer insurance to expand the popularity and increase insured amount.
2.Make up the advisory group of medical care to offer the medical science professional suggestion of a dispute of claim settlement.
3.Hold the meeting of the craft to discuss the method to the solution and improvement in disputes of claim settlement regularly.
4.Draft the insurance demonstration clause of the cancer, and unify the norm of the characters and content of the clause.

並列關鍵字

Cancer insurance ； Claim dispute ； Lawsuit ； Complaint

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