從醫學觀點論傷害保險之保險事故──以感染症為例

Discussion on Insured Perils of Injury Insurance From the Medical Point of View---Focus on Infectious Diseases

傷害保險所承保之危險事故為意外傷害，即使保險法對意外傷害為「非由疾病引起之外來突發事故所致者」之解釋性規定，然學說與實務對此「非疾病引起」、「外來」及「突發」三要件之概念，尚無一客觀判斷標準，歷年來爭議不斷。其中，被保險人因感染症所致之傷害或死亡是否屬於傷害保險承保範圍，過去學說與實務通說皆採否定見解，但近年來卻被挑戰，逐漸成為常見之保險糾紛。本文認為，保險法對於「意外傷害」業已明文定義，卻未對「疾病」下定義，應是將人之傷害或死亡原因區分為「意外」與「非意外」所致，意外傷害為「外來且突發」事故，而「非疾病引起」即為「外來且突發」之意。雖然在一般情況下，絕大多數非因先前意外傷害所導致之後續感染屬疾病之範疇，但在少數例外情形，非存在於人體內之病原由體外進入，並迅速造成被保險人之傷害，則此感染症應可由被保險人舉證其符合「外來突發」之意外傷害事故，屬於傷害保險承保範圍，保險人應負理賠之責。

The perils covered by the personal accident insurance are injury by accident. Even if the“injury by accident”is defined in insurance law as“physical harm caused by unforeseen external sudden events other than disease”, there is no objective criterion for judging the three elements of“non-illness-caused”,“sudden”and“external”in theory and practice, and the related disputes are still unsolved in recent decades. The injury or death of the insured due to infectious diseases is not covered by the injury insurance is the majority in theory and practice. However, this opinion has been challenged in recent years and has gradually become a common insurance dispute. This author opines that the insurance law has defined the phrase“injury by accident”, instead the term“disease”. It should be due to the division of injury or death into“accidental”and“non-accidental”. Accidental injuries are defined as“external and sudden”accidents, while“other than disease”means“external and sudden”. Therefore, under normal circumstances, most subsequent infections are not caused by previous accidental injuries and fall within the scope of diseases. However, in a few exceptional cases, if pathogens that do not exist in the human body enter from outside the body and quickly cause injury to the insured , then the infectious disease should be able to be proved by the insured that it meets the“foreign sudden”accidental injury accident, which is covered by the injury insurance, and the insurer should be responsible for the claim.