保險法上合理期待原則於我國法之實踐──必要性醫療爭議事件為例

Practice of Reasonable Expectations Doctrine in Taiwan Insurance Law: Example of Contested Cases of Medical Necessity

保險業使用定型化契約作為與保險消費者締約，並採取全盤接受或離開之基礎，造成當事人間之資訊不對稱。於美國法上，法院為調整資訊不對稱所造成的不公平情況，於判例法上發展出合理期待原則，並由知名保險法學者Robert Keeton歸納而說明之。然而，合理期待原則於美國並未發展出具體化的適用要件，多數州遂採取修正版的合理期待原則，用於保險爭議案件中，作為契約解釋性的工具。我國保險法雖未有合理期待原則之規定，但於20多年前，已有下級法院於案件採用合理期待原則，嗣後我國最高法院亦採用合理期待原則作為解決保險爭議案件之基礎。本文以合理期待原則於理論之發展，建議五個適用合理期待原則應考量的具體要件，並檢視合理期待原則於我國人身保險必要性醫療案件之實踐，提出分析與檢討，以利未來法院及爭議處理機構以合理期待原則作為解決保險爭議的基礎。

In the insurance industry, insurers use standardized forms as the basis for entering into contracts with insurance consumers, often on a take-it-or-leave-it basis. This approach leads to information asymmetry between the contracting parties. In the United States, courts developed the doctrine of reasonable expectations in the common law system to address the unfair situations caused by such information asymmetry. This doctrine was summarized and explained by Robert Keeton, a well-known insurance law scholar. However, the specific elements for applying the reasonable expectations doctrine in the American legal system have not been fully developed. The majority of states have adopted a modified version of the reasonable expectations doctrine and use it in insurance disputes as an interpretative tool to supplement the contents of insurance contracts. Although this doctrine has not been explicitly stipulated in Taiwan Insurance Law, lower courts began adopting it in cases over two decades ago. Eventually, the Taiwan Supreme Court also adopted the doctrine as the basis for resolving insurance dispute cases. The results demonstrate that five specific elements, based on the theoretical development of the doctrine should be considered in a application and examination of its practice in cases of medical necessity. The study conducts an analysis and review in the hope that its findings can further improve how courts and dispute resolution institutes resolve insurance disputes based on the reasonable expectations doctrine.