pennbattle310000| The customer is in critical condition and fails to seek medical treatment at the hospital agreed in the policy. Can the medical expenses of nearly 300,000 yuan be settled? The court ruled this

Original title: the client was in critical condition and failed to see a doctor in the hospital stipulated in the insurance policy. Can you settle the claim for nearly 300000 yuan of medical expenses?Pennbattle310000? This is how the court ruled | an outsider

Interface News reporter | Lu Wenqi

In the case of serious illness, can the patient settle the claim if he is unable to see a doctor in the second-level or above hospital required by the insurance company? Recently, the Chengdu-Chongqing Financial Court concluded an insurance contract dispute case in the second instance, providing a reference for the relevant situation.

Xiao's mother, Zhang, took Xiao as the insured and took out insurance with Sichuan Branch of a Life Insurance Co., Ltd.Pennbattle310000Care for millions of Medical Insurance. The insurance clause stipulates that during the validity period of the contract, the insurer shall bear the responsibility of paying general medical insurance and malignant tumor medical insurance. The approved hospitals are the general departments of public hospitals at or above the second level in the hospital classification of the Ministry of Health.

Later, Xiao was diagnosed with acute T-lymphoblastic leukemia in a third-class hospital in Sichuan. Treatment records show that the hospital adopted two different chemotherapy schemes for Xiao, the results were not ideal, and there was an urgent need for bone marrow transplant, while there were many other patients waiting for bone marrow transplant in the hospital at that time. If the operation is not carried out in time, it is easy to miss the best time for diagnosis and treatment.

Xiao then went to two hematological hospitals in Hebei and Beijing for examination and treatment to avoid the deterioration of his condition. After that, Xiao asked for a claim for more than 300,000 yuan of out-of-pocket expenses after medical insurance reimbursement. The insurance company refuses compensation on the grounds that the two specialized hospitals in Hebei and Beijing are not public hospitals at or above the second level. Xiao then sued to the court.

The court of first instance confirmed Xiao's voluntary deductible of 20, 000 yuan and ordered the insurance company to pay Xiao's insurance money of 286946.Pennbattle310000.3 yuan. The insurance company filed an appeal.

The Chengdu-Chongqing Financial Court held that the provisions of Article 20 of the Supreme people's Court on the interpretation of several issues concerning the Application of the Insurance Law of the people's Republic of China (3), the purpose is to prevent individual insurants from maliciously evading the medical institutions agreed in the insurance contract and abusing the right of insurance claim, and this is not the case.

Xiao is suffering from a major illness. after being admitted to the hospital approved by the insurance contract, due to the shortage of medical resources, if the bone marrow transplant is not completed in time, there is a risk of threatening life and health. Although the hematological specialist hospital transferred due to critical condition is not a medical service institution agreed in the insurance contract, it can provide patients with much-needed medical treatment. Xiao's transfer to hospital is urgent and reasonable. It belongs to the situation of "seeing a doctor immediately because of an emergency".

Moreover, the insurance company did not provide evidence to prove that the cost spent by Xiao in other hospitals was significantly higher than that of similar drugs and excessive medical treatment, so the insurance premium should be paid in accordance with the agreement of the insurance contract. The appeal was dismissed and the original verdict was upheld.

According to the interpretation of the Supreme people's Court on several issues concerning the Application of the Insurance Law of the people's Republic of China (3), Article 20 stipulates that if the insurer refuses to pay the insurance money on the grounds that the insured has not received treatment in the medical service institution agreed upon in the insurance contract, the people's court shall support it, except where the insured must seek medical treatment immediately due to emergency circumstances.

The Chengdu-Chongqing Financial Court pointed out that after an accident, the first thing to consider is to treat the injured in a timely manner. No matter which hospital it is in, it is inevitable to incur medical expenses, and the insurance company refuses compensation only on the grounds that it is not treated in the agreed medical institution, which is contrary to the principle of fairness and justice. The reasonable definition of the exception to the provisions of the agreed medical institutions by the people's court reflects the judicial respect for the right to life and health, and provides legal protection for the people to accept universal, convenient and timely medical security.

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