Perspective | Can insurance companies refuse to compensate for "non-medical insurance drugs" costs in traffic accidents?
Published:
2024-10-25
In traffic accidents, medical expenses arise from injuries, but insurance companies often refuse to compensate by claiming that the costs for "non-medical insurance drugs" are not covered. This article analyzes whether insurance companies can refuse compensation for the "non-medical insurance drug" portion of medical expenses, in conjunction with relevant laws, regulations, and practical cases.
Preface
Medical expenses arise from injuries sustained in traffic accidents, but insurance companies often refuse to compensate by claiming that the costs of "non-medical insurance drugs" are not covered. This article analyzes whether insurance companies can refuse compensation for the "non-medical insurance drug" portion of medical expenses in conjunction with relevant laws, regulations, and practical cases.
I. Relevant Cases
1. Civil second-instance judgment of a traffic accident liability dispute involving a certain insurance company in Zibo City and Sun - Case No: (2022) Lu 03 Min Zhong 593.
The second-instance court held: According to the relevant provisions of the judicial interpretation of the Insurance Law, if the insurance contract stipulates that medical expenses are determined according to the standards of basic medical insurance, the insurer's refusal to pay insurance benefits on the grounds that the insured's medical expenses exceed the scope of basic medical insurance is not supported by the people's court. The appellant's claim that the insured did not purchase insurance for medical expenses outside of medical insurance, thus the 7100.05 yuan for non-medical insurance drugs should not be borne, has no corresponding legal basis.
2. Civil second-instance judgment of a traffic accident liability dispute involving a certain insurance company in Zhoukou and Chen, Wu - Case No: (2024) Xiang 11 Min Zhong 1229.
The court held: The defendant insurance company's claim that the medical expenses exceeding the standard of basic medical insurance do not fall within the scope of compensation is not supported. The first-instance court held that the plaintiff, who was injured in a traffic accident, needed timely treatment, and during the treatment period, the medical institution used medication based on the victim's condition. The plaintiff, as the injured party, found it difficult to distinguish between medical insurance drugs and non-medical insurance drugs, which exceeded the injured party's duty of careful attention. Moreover, if the medical institution needed to use drugs beyond the scope of medical insurance during the rescue and treatment of the injured but did not do so, it would violate the principle of putting people first and saving lives, which is not conducive to the treatment of the injured or the timely resolution of traffic accident disputes. Additionally, the defendant insurance company did not provide effective evidence to prove that the victim's non-medical insurance drug expenses were unreasonable or unnecessary treatment costs, so this claim by the defendant insurance company was not accepted.
3. Civil second-instance judgment of a traffic accident liability dispute involving a certain insurance company in Jining and Du - Case No: (2021) Lu 08 Min Zhong 591.
The second-instance court held: Regarding the claim to deduct non-medical insurance drug expenses, this court believes that after a traffic accident, the measures to be taken for the injured during treatment and the resulting medical expenses cannot be decided by the injured party, the policyholder, or the appellant. The appellant did not provide evidence to prove that the incurred non-medical insurance treatment costs were unreasonable, and the appellant should bear the compensation responsibility for the reasonable medical expenses arising from the accident. The appellant's claim to deduct non-medical insurance expenses lacks legal basis, and this court does not support it.
II. Lawyer's Analysis
Article 19 of the "Interpretation of Several Issues Concerning the Application of the Insurance Law of the People's Republic of China (III)" states that if the insurance contract stipulates that medical expenses are determined according to the standards of basic medical insurance, the insurer's refusal to pay insurance benefits on the grounds that the insured's medical expenses exceed the scope of basic medical insurance is not supported by the people's court; if the insurer has evidence proving that the expenses incurred by the insured exceed the standard of similar medical expenses under basic medical insurance, the people's court should support the request to refuse payment for the excess. Article 6 of the "Interpretation of Several Issues Concerning the Application of Law in Personal Injury Compensation Cases" states that medical expenses are determined based on the payment receipts issued by medical institutions, combined with medical records and diagnosis certificates. Medical expenses are a compensation item clearly stipulated by law, and the insurance company should compensate for the medical expenses incurred in treating injuries from traffic accidents.
According to the above legal provisions, our lawyers believe that, firstly, in traffic accidents, medical expenses are a compensation item clearly stipulated by law, and the insurance company should compensate. Secondly, the clause regarding the deduction of "non-medical insurance drug" expenses in the insurance contract is a format clause that the insurance company has drafted to benefit itself, exempting or limiting its own liability, and is therefore invalid. Furthermore, the agreement to refuse compensation for "non-medical expenses" also violates the provisions of Article 19 of the judicial interpretation of the Insurance Law (III). Finally, the national basic medical insurance is a welfare-oriented social insurance system. The medical treatment is the hospital's action, and during the treatment process, neither the tortfeasor nor the victim can foresee or control the treatment methods and medication scope taken by the hospital based on the condition. The restriction clause on medication within the scope of medical insurance clearly reduces the insurer's risk and limits the rights of the insured. If the insurance company refuses to pay, it is clearly unfair, and therefore the costs of non-medical insurance drugs should not be deducted.
III. Relevant Suggestions
Due to the increasing number of motor vehicles, the occurrence of traffic accidents is on the rise. After a traffic accident, it is important to keep good records of medical visits, payment records, invoices issued by hospitals, and other evidence, and to promptly request compensation from the insurance company. If the insurance company refuses to pay for "non-medical insurance drug" expenses, you may hire a professional lawyer to protect your legal rights.
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