併發症、保險理賠與合理期待原則

Complication, Insurance Coverage and the Reasonable Expectation Doctrine

在保險理賠實務上，疾病與理賠範圍之認定常有疑義。特別是因疾病本身、或是治療手段引起之併發症或後遺症等，是否在保險理賠範圍內，實務上多有爭議。本文以為此類爭議與被保險人之合理期待有關，發源自美國法之合理期待原則應值得參酌。故本文整理我國相關判決與評議決定，並提出本文之建議。就結論而言，由於一般被保險人甚難理解疾病本身、併發症與後續症狀之差異，只要與該病症或其治療經常合併伴隨發生而有醫療必要者，即應可考慮認定屬於理賠範圍。如保險人欲將特定併發症排除，應經特定具體之除外約款而排除之，否則即應以被保險人之客觀合理期待為準。 In insurance claim practice, the recognition of sickness and insurance coverage is ambiguous. In particular, whether the complication or sequela resulted from sickness itself or medical treatment is within insurance coverage or not is usually controversial. This paper argues that this issue generally involves with reasonable expectation of insured, and thus the reasonable expectation doctrine which developed in the U.S. is worth more consideration. This paper analyzes the relevant judgments of courts and decisions of Financial Ombudsman Institute, and then provides relevant suggestions. In conclusion, insured usually does not have the profession to distinguish sickness, complication or sequela. As long as that loss usually happens with sickness and there is necessity of medical treatment, then that loss shall be considered within insurance coverage. The complication can be excluded by specific exclusion in insurance policy, otherwise the objective reasonable expectation shall prevail.