Liu Xiaozhen was laid off in middle age. Fortunately, she was in good health and was not picky about her work. She was soon hired by a domestic company. Life is not too heavy, and income is more than a thousand yuan. Liu Xiaozhen feels very satisfied.
Liu Xiaozhen served the family, the hostess surnamed Li, Liu Xiaozhen called her Li Jie. Li Jie is very enthusiastic. She has already retired in the unit. She is too busy. She goes to an insurance company in the city to do business agents, which is to sell insurance. On that day, after the busy work, Li Jie took Liu Xiaozhen to sit down and pulled up her family. The two said and said, Li Jie said about the insurance, she said: “I said Xiaozhenmei, buy a medical insurance, it is very cost-effective.”
Liu Xiaozhen smiled and said: “Li Jie, you see that I am in good health, what medical insurance do I buy? Besides, I have no life in my life. Where can I buy insurance?”
Li Jie said: “This medical insurance, you usually do not have a disease, you can’t see the benefits of it, but how can people eat whole grains without getting sick? If you don’t say anything, if you really come across On such a day, you can regret it for not buying it at the beginning!”
Li Jie said, got up and brought a kind of insurance information called “health regular insurance”, recommended to Liu Xiaozhen, she also said that this kind of medical insurance is not expensive, the average person can afford it.
Liu Xiaozhen repeatedly read the information several times. The information is very clear. That is, you pay the insurance company a “health insurance” premium of 1008 yuan per year. If the insured person diagnoses the first time within half a year after signing the contract, For diseases, the insurance company must give a minimum of 35,000 yuan in major illness insurance.
After reading the information, Liu Xiaozhen still hesitated, after all, it cost more than a thousand yuan. Li Jie did not lose the opportunity to stop lobbying. In the end, Liu Xiaozhen was said to have moved and promised to buy such a piece of insurance. The next day, Li led Liu Xiaozhen to the insurance company, paid insurance premiums, and signed an insurance contract. In the signed “Healthy Life Insurance Contract”, the interpretation of major diseases and heart diseases was also made in the form of a major disease including heart disease (myocardial infarction).
A sway is half a year has passed.
This morning, Liu Xiaozhen was preparing to go out to work, and suddenly felt that she was somewhat uncomfortable. Her husband was busy sending her to the hospital for examination. After a preliminary diagnosis by the hospital, Liu Xiaozhen’s heart is considered to have diseases and needs hospitalization.
Liu Xiaozhen thought that he would buy “health regular insurance” and asked the doctor if it was a serious illness. The doctor said that of course.
After discussing with her husband, Liu Xiaozhen explained the condition to Li Jie and went to the hospital designated by the insurance company for hospitalization.
Liu Xiaozhen was suffering from rheumatic heart disease. He lived in the hospital for 15 days and also underwent surgery. He spent nearly 36,000 yuan. After Liu Xiaozhen was discharged from the hospital, according to the provisions of the insurance contract, he wrote a claim for payment, holding relevant information, and led by Li Jie to find an insurance company.
They were treated by a manager surnamed Wang. Manager Wang was very polite. He accepted the application submitted by Liu Xiaozhen and said, “Your situation has been told to us by Li Jie. The information has also been reported. We will seriously study it. You are at home and have news.” After listening to Manager Wang, Liu Xiaozhen was very moved and felt that the insurance company was talking.
A week later, the insurance company returned a letter to Liu Xiaozhen. Liu Xiaozhen never imagined that the insurance company replied that her heart disease was not covered by insurance. The specific reason was that the insurance company provided the format clause in the contract clearly stating “heart disease (myocardial infarction)”, that is, heart disease only Refers to myocardial infarction, and Liu Xiaozhen got rheumatic heart disease, which is a chronic disease, so the insurance company refused to pay.
Liu Xiaozhen was awkward. When he bought insurance, he was able to protect himself in case of serious illness, and he also made it clear when signing the contract. How could it become worse? Liu Xiaozhen came to the law firm with a stomachache. A lawyer surnamed Zhang looked at the materials and listened to her story and suggested that she file a lawsuit against the insurance company.
On the day of the court session, Mr. Zhang represented Liu Xiaozhen in the courtroom, but the insurance company insisted on refusing to pay.
After all, the law is fair. In the end, the court held that the plaintiff Liu Xiaozhen delivered the premium after insuring the defendant insurance company, and the contract was legal and valid. After Liu Xiaozhen became ill, he asked the insurance company to pay the insurance premium, which belongs to the insurance coverage agreed by the insurance contract of both parties and should be supported. The insurance company’s statement that “heart disease refers only to myocardial infarction”, according to the law, if the parties have disputes over the terms of the contract, they should make an explanation that is unfavourable to the party providing the format clause. Therefore, the defense company’s defense can not be established, the court ruled that the insurance company lost Liu Xiaozhen health life insurance premium of 36,000 yuan.
The party providing the format clause violates the principles of honesty, credit, and fairness, and makes the terms of the contract ambiguous. Although the annotation section explains the ambiguity clause, it should still make an explanation that is not conducive to the party providing the format clause. The focus of the dispute between the two parties in the case, the defendant, that is, whether Liu Xiaozhen’s heart disease is covered by insurance should be judged as follows: “Cardiac (myocardial infarction)” should be understood as a heart disease including myocardial infarction, etc. It is understood that “heart disease” refers only to “myocardial infarction”. Therefore, the heart disease of the plaintiff Liu Xiaozhen should be covered by health insurance.