商业健康保险手术医疗保险金给付纠纷之研究.PDFVIP

2011 保險金融管理學術暨產學合作研討會 商業健康保險手術醫療保險金給付糾紛之研究 商業健康保險手術醫療保險金給付糾紛之研究 蘇文斌(朝陽科技大學保險金融管理系副教授) 吳桂桂(朝陽科技大學休閒事業管理系助理教授) 李俊德(富邦人壽保險股份有限公司理賠部副理) 陳家郁(朝陽科技大學保險金融管理系研究生) 摘要 現代醫療技術日新月異，許多侵入性手術已逐漸發展為較小範圍的微創手術或雷射 或超音波或電燒或放射線…等其他治療方式可以替代，而對該疾病同樣可以達到治療的 效果。對於因為科技的進步而發展出新的手術或治療方式而取代傳統外科手術者，常有 無法獲得手術醫療保險金理賠給付，或以較低之手術等級，或較少之手術醫療保險金給 付，進而產生理賠糾紛與爭議。 期盼透過合理期待原則的應用來減少商業健康保險理賠的糾紛與爭議，回歸保險制 度損害賠償的原意，做有利於大多數被保險人之解釋，且符合不同時代背景與科技發展 之進步之考量，以達到大多數人的合理期待。期能降低保險理賠的糾紛與爭議，使被保 險人能獲得應有的理賠給付，且能減輕理賠人員的工作壓力，維護保險公司的良好形 象，並實現保險制度的真諦。 關鍵字：商業健康保險、手術醫療保險金、理賠糾紛、合理期待原則 Abstract The fast-changing modern medical technology, many of the invasive surgical procedures have gradually developed into smaller-scale mini-invasive surgery, or have been replaced by laser, ultrasound, electrical burn, radiation, or other treatments with the same results. For the traditional surgery that have replaced by newly developed methods of treatment or surgery due to technological advances, one often can not obtain surgery and medical insurance payout, or only receives a lesser amount at a lower surgery tariff level, leading to claims disputes and controversy. Hopefully through the application of the principle of reasonable expectation, the disputes and controversy in commercial health insurance claims can be reduced, and the original intent of the insurance system can be restored, thereby providing a satisfactory explanation to the majority of the insured. This will align with the consideration of different background setting and progress in technological development, and fulfill the reasonable expectations of most people. It is hoped that this will reduce insurance claims disputes and controversies, so that the insured can receive the claim payout he or she deserves. This will also alleviate the pressure of claims staff, maintain a