After the outbreak, many insurance companies took advantage of the situation to launch "isolation insurance". But in the actual compensation, it encountered difficulties Recently, when Ms. Shen in Shanghai applied for isolation allowance, the insurance company refused to pay compensation for several times on the grounds that "there are no medium and high risk areas in Shanghai during this period".
Author: chenweijing
"Isolation insurance" is essentially "accident insurance"
According to relevant contract terms, if the insured becomes a close contact of new crown patients, or is isolated centrally or at home due to being in a medium - and high-risk area, he can receive isolation allowance of 200 yuan a day, with a ceiling of 6000 yuan.
The number of confirmed cases is usually the basis for the division of medium - and high-risk areas. However, in practice, some places will adopt different standards, and the delimitation of medium and high-risk areas is often through administrative means. The insurance company refused to pay compensation accordingly, which made it difficult for many insured to accept.
In response to the problem of "isolation insurance", in March this year, the cbcirc ordered all banking and insurance regulatory bureaus and property insurance companies to send letters to rectify relevant businesses.
A legal person mentioned that the exemption of liability for isolation reasons only stipulates the centralized isolation exemption for returnees from non medium and high-risk areas and non whole closed management areas. "In combination with the product terms and exemption terms, most of the isolation caused by the new crown should be included in the scope of protection."
When "online Red insurance" encounters difficulty in compensation
As early as the beginning of 2020, dozens of insurance companies expanded their insurance liability to COVID-19. After that, many companies took advantage of the situation to launch "isolation insurance". According to incomplete statistics, there were more than 60 kinds of "isolation insurance" in the market at the peak, including large insurance companies such as China Life Insurance and Ping An insurance.
"As long as a cup of milk tea money", some insurance sales even made this slogan. With a low premium and a considerable amount of coverage, the "isolation insurance" has become a "net red insurance" for a while. In the eyes of many people, the "isolation insurance" ranging from a few yuan to dozens of yuan can "buy peace of mind". However, after that, it was difficult to settle claims and complaints, which once plunged this "online Red insurance" into a whirlpool.
"At the beginning of March, epidemics began to appear all over the country. Because our company has a lot of business trips, many colleagues may be required to be isolated just because they are in the same carriage." Zhang Li, who lives in the Pudong New Area of Shanghai, told China Newsweek that she wanted to hand over such risks to the insurance company. She and several colleagues of the company purchased an accident insurance under Zhong'an insurance. In addition to accident, disability, etc., the insurance also attached a specific infectious disease extended isolation allowance insurance clause including Xinguan.
According to the contract, if the insured is notified by the local government or the epidemic prevention department to implement centralized isolation or home isolation due to close contact with patients suffering from novel coronavirus pneumonia, or because he is in a medium and high-risk area, he shall be paid a specific infection isolation allowance according to the actual isolation days of the insured.
The insured amount of this insurance is 59 yuan. After a few days' waiting period, those who meet the claim settlement requirements can get an isolation allowance of 200 yuan a day and a ceiling of 6000 yuan.
Many types of "isolation insurance" have the above similar claim settlement standards. Last December, Li Yue, who lives in Pudong New Area, purchased Fosun United Love worry accident insurance, which is valid for one year. "In case of isolation, there is another channel to make up for some losses.".
At present, Shanghai has been restarted, but Zhang Li and Li Yue did not get the expected settlement of claims, for the same reason that they did not belong to medium and high risk areas. "The certificate issued to me by the government can prove that I have been under closed management since March 16," Li Yue said that he could not understand it.
China Newsweek noted that the above two "isolation insurance" have been taken off the shelves. At present, there are not many related products on sale. With the development of the epidemic and the increase in the number of buyers, this kind of insurance has also experienced iteration. In addition to the increase in the premium, some areas with high epidemic incidence have also been excluded from the coverage.
According to CCTV finance and economics, in addition to the high complaint rate, a large number of claim settlement applications are also an important reason for the "isolation insurance" off the shelves. At the end of 2021, the practice and experience of China's banking and insurance industry in combating the COVID-19 released by the China Banking and Insurance Regulatory Commission disclosed that in 2020, the amount of exclusive insurance claims for the insurance epidemic had reached 490million yuan.
Dissatisfaction with insurance company's refusal
The unclear, unreasonable and inconsistent compensation standards are the root causes of insurance compensation disputes.
On May 25, the well-known consumer service platform black cat complaint [complaint portal] disclosed that recently, many consumers reported the rejection of isolation insurance on the black cat complaint platform. At present, the number of complaints about isolation insurance is as high as 2751. Some consumers said that Zhong'an insurance refused to settle claims on the ground that there were no medium and high-risk areas in Shanghai; Some consumers said that the claim assessment of Fosun United health insurance was unreasonable. They successfully applied for claim settlement in the same community and unit, and submitted the same materials, but they were rejected.
In addition to the above, the common exemption causes of insurance companies include "no compensation for asymptomatic infections". In this round of epidemic, the cumulative number of positive infections in Shanghai has exceeded 600000, of which about 90% are asymptomatic.
"All the leading companies have designed this product, which has also been put on record, indicating that it is supported by supervision and can solve the problem, not a 'wonderful insurance'", a staff member of Zhong'an insurance told China Newsweek that insurance companies design products based on big data, but a large-scale epidemic like Shanghai has exceeded the calculation, and there are also many complex situations.
Suspected cases, confirmed cases and asymptomatic infections are listed separately in the infectious source control items in the prevention and control plan for novel coronavirus pneumonia (Eighth Edition). The number of confirmed cases is usually the basis for the division of medium and high-risk areas.
However, in practice, some regions will adopt different standards. In addition, the delimitation of medium and high-risk areas is often through administrative means.
Lawyer: most of the isolation caused by the new crown should be included in the scope of protection
"Our community has been a sealed zone for a long time. That's why I think we should pay compensation according to the column of medium and high risk. Li Yue said that she has contacted the customer service three times, but was refused compensation because she could not prove that it was a medium and high risk area.
Zhang Li received two "suggestions" from the insurance company. One was to provide the close connection certificate issued by the housing committee / epidemic prevention Office, and the other was to wait for the government to release the corresponding high-risk documents of the sealed zone. When the epidemic was at its worst, the two of them were in an area where new positive infections were found every day.
On social platforms, there is no lack of controversy over whether insurance companies should pay compensation.
"This has something to do with Shanghai's epidemic prevention policy, which is not written in the terms. Not only we, but also the whole industry have some disputes, and the regulatory authorities have no unified statement." the staff of Zhong'an insurance explained that they will communicate from the perspective of the best interests of users, hoping that the products can reflect the original intention of risk protection.
A person in the insurance industry told China Newsweek that although Shanghai has not demarcated the area according to the medium and high risk standards at this stage, if the environment of the insured objectively meets the above standards, the reason given by the insurance company for refusing to pay compensation is questionable.
According to the source, "isolation insurance" essentially belongs to "accident insurance". In principle, it is unpredictable, external and unintended. "For example, the matter of sprain of the foot cannot be predicted that the next step will be empty.". With regard to insurance compensation, insurance companies should adhere to the principle of "must compensate for what can be compensated or not" and "in order to let the public know that insurance is to protect everyone's interests".
Xuxianhui, director of Beijing Jingrui law firm, introduced to China Newsweek that "presumption" is allowed in civil litigation disputes, that is, "lifting weights to show lightness and lifting weights to show heaviness". For example, the parties can give examples of what the status of medium - and high-risk areas is.
"As an insurance product permitted by the CIRC, since it is called insurance, the first thing to protect is risk, and the product itself certainly has risks." Xuxianhui said.
Mo Zhe, a lawyer of Jiangsu Daqiao law firm, said that according to the insurance law, if the insurer and the applicant, the insured or the beneficiary have disputes over the terms of the insurance contract concluded with the standard terms provided by the insurer, they should be interpreted according to the common understanding. If there are two or more interpretations of the contract terms, the people's court or arbitration institution shall interpret them in favor of the insured and the beneficiary. That is, there are different interpretations of the insurance clauses, and the principle that the interests belong to the insured or the beneficiary.
Mo Zhen believes that the exemption of responsibility for isolation reasons only stipulates the centralized isolation exemption for returnees from non medium and high-risk areas and non whole closed management areas. "In combination with the product terms and exemption terms, most of the isolation caused by Xinguan should be included in the scope of protection."
(Zhang Li and Li Yue in this article are pseudonyms)