The Scope Of The Claim Is Not Covered. The Company Is Sentenced To Pay For The Non Medical Insurance Expenses.

A traffic accident that causes casualties is caused by the use of "non medical insurance drugs" in the treatment after the accident, and the insurer and the insurance company insist on each other. A few days ago, the court of second instance made a final judgment. The insurance company did not explain the obligation of the exemption clause which is not covered by the medical insurance expense, and there was no proof that the medical expenses paid by the insurance company were not covered by the medical insurance.

In June 25, 2013, a freight company driver and a motorcycle were killed in a traffic accident. Motorcycle driver Hou Mou was seriously injured. On March 2014, Hou took the freight company and an insurance company underwritten by the vehicle company to the court on the compensation for the traffic accident. In June 11th of that year, the three party reached a conciliation under the auspices of the court. According to the conciliation statement, the freight company paid 19988.6 Yuan medical expenses in the accident, and the freight company went to the insurance company to claim it on its own.

But what the freight company did not expect is. When they make claims, the insurance company only reimburse the freight company for medical expenses of 13208.8 yuan, and for the remaining 6779.8 yuan, the insurance company refuses to pay. After several times of failure, the freight company had to sue the insurance company to the court.

In the trial, the defendant argued that the insurance company had not paid 6779.8 yuan because the medical expenses of the injured person were not the cost of medical insurance, and the cost of non medical insurance should not be the scope of the claim, so it should be deducted.

The court held that the insurance contract between the two sides was related. legitimate Effective. The insurance company raised 6779.8 yuan in the case of a non medical insurance cost which could not be claimed. However, no evidence was provided to prove the composition of the non medical insurance cost, and no evidence was provided to prove that the non medical insurance expenses generated by Hou's treatment were included in the expenses of the freight company. Therefore, the insurance company should bear the consequences of the burden of proof. In December 2014, the court made a first instance judgment, the defendant paid the plaintiff compensation 6779.8 yuan, and doubled the debt interest during the delay in performance.

The insurance company refused to accept the appeal. The second instance concluded that the case Automobile insurance contract The "compensation for medical expenses" shall be defined in accordance with the provisions of the guide for the clinical diagnosis and treatment of traffic accident personnel and the national basic medical insurance standard, and the categories of medical supplies shall be restricted, which shall be part of the clauses that exempt insurers from liability. Insurance company There is no sufficient evidence to prove that the obligation is clearly stated. Moreover, the insurance company has not shown that the medical expenses that have not been paid are in the range of non medical insurance. Accordingly, the court's final judgment dismissed the appeal and upheld the original judgment.