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The court found that the agreement on "serious epilepsy" in the serious disease insurance contract signed by both parties was as follows: the diagnosis must be made by neurologists or pediatricians according to typical clinical symptoms and imaging examinations such as electroencephalogram and tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET); Relevant medical records of more than 6 months must be provided to prove that the insured has repeated tonic clonic seizures or grand mal seizures that are ineffective after drug treatment, and has undergone neurosurgery.
In order to find out whether the examination and operation mentioned in the clause are necessary means of diagnosis and treatment, the court went to the neurology department and pediatrics department of two local top three hospitals to investigate, learned the diagnosis of epilepsy by existing medical technology, and could be diagnosed through typical clinical symptoms and EEG. "Tomography and MRI" mentioned in the contract are the means to identify the cause of disease for subsequent treatment, not necessary for diagnosis. In addition, the vast majority of epileptic diseases cannot be treated surgically, which can be confirmed as serious epilepsy in combination with the current situation of the insured and medical records.
The court held that the definition of serious epilepsy in the terms involved in the case greatly limited the scope of claims for the disease, deviated from the common cognition of ordinary people and common means of diagnosis and treatment, and actually exempted or reduced the insurer's insurance liability, which should be recognized as an exemption clause. According to the Insurance Law, insurance companies should make prompt on the application form, insurance policy or other certificates that can draw the attention of the applicant Delicious 2 HD online viewing And explain to the applicant. However, the contract involved in the case only regarded this clause as a general insurance clause, which was not highlighted. The insurance company also did not make an easy to understand explanation and explanation to the applicant about the concept, content and legal consequences of the disease. Accordingly, the court held that the above disease definition clause did not become the content of the insurance contract and did not take effect.
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