【作者】 李彤；

【导师】 潘红艳；

【作者基本信息】 吉林大学 ， 法律硕士（非法学）（专业学位）， 2024， 硕士

【摘要】 重疾保险发明之初就是为了防止患者因病致贫或者因病返贫,但是现实中由于法律制度不够完善,司法适用存在混乱使得重疾保险消费者申请理赔时困难重重。本文采用实证研究的方法,通过搜集整理大量的案例发现,重疾保险消费者发生理赔纠纷时的争议焦点在于投保人的如实告知义务和保险人免责条款明确说明义务。通过选取典型案例进行进一步的分析发现在投保人如实告知义务方面,问题在于违反如实告知义务的认定模糊、如实告知义务主体范围狭窄、合同复效是否应二次告知认定不一。在保险人免责条款明确说明义务方面,问题在于免责条款认定混乱、认定义务履行不统一、不利解释规则的滥用。重疾保险消费者与传统消费者相比具有特殊性,因此对重疾保险消费者的保护也不同于传统消费者。对于传统消费者而言,因为信息不对称的劣势地位,现行以《消费者保护法》为代表的法律体系对其实施倾斜性保护。但是保险消费者从其“时空间离”的特性和交易“信息不完全”的特征来看,对其采用倾斜性保护并不适宜,而应代之以双边促进的理念。事实上,近年来学界也多主张要注意对消费者倾斜性保护的谦抑性。因为过多先入为主的倾斜性保护会增加经营者的“潜在经营成本”,最终反馈在价格的承担者即消费者身上。这与消费者保护背道而驰。这在保险消费者保护中也同样适用。在重疾保险司法实践中,法官多以结论倒推逻辑,以倾斜保护投保人、被保险人为宗旨,严格保险人的责任。这样与公平相背,不利于保险业健康发展,也背离了保护保险消费者的初衷。基于此,本文对上述在案例中发掘的问题进行深入分析,并秉承保护重疾保险消费者群体利益的理念提出完善建议。在投保人如实告知义务方面:第一,统一重疾保险投保人违反如实告知义务的标准,主观上划分认定“故意”与“重大过失”的界限,客观上扩充现有的因果关系标准内容。第二,拓展如实告知义务主体范围,被保险人也应作为义务主体。第三,明确保险合同复效应二次告知。在保险人免责条款说明义务方面:第一,采用中间立场的解释方法解释免责条款,可以避免以往法律功能主义的弊端。第二,从形式标准和实质标准两个方面认定履行标准,统一裁判尺度。第三,规范利用不利解释规则,在处理格式条款时,首先应根据《民法典》第142条和466条的规定进行一般性的解释。只有当一般解释规则不能明确具体含义时,才能适用不利解释规则。更多还原

【Abstract】 The invention of serious illness insurance is to prevent patients from being poor or returning to poverty due to illness.However,in reality,due to the imperfect legal system and the confusion of judicial application,serious illness insurance consumers have difficulties in applying for claims.This paper adopts the method of empirical research and finds that the focus of disputes when serious illness insurance consumers have claims disputes lies in the truthful disclosure obligation of the insurer and the clear obligation of the insurer in the exemption clause.Through the selection of typical cases for further analysis,it is found that in terms of the insurer’s truthful disclosure obligation,the problem is that the identification of the violation of the truthful disclosure obligation is fuzzy,the subject scope of the truthful disclosure obligation is narrow,and whether the contract resumption should be twice told is different.In terms of the insurer’s obligation to clearly state the obligation,the problem is that the identification of the exemption clause is confusing,the identification of the obligation is not unified,and the abuse of the adverse interpretation rule.Compared with traditional consumers,serious illness insurance consumers have particularity,so the protection of serious illness insurance consumers is different from that of traditional consumers.For traditional consumers,because of the disadvantageous position of information asymmetry,the current legal system represented by the Consumer Protection Law implements preferential protection for them.However,from the perspective of the "time-space separation" characteristics and the "incomplete information" characteristics of the transaction,it is not appropriate to adopt the preference protection for the insurance consumer,but should be replaced by the concept of bilateral promotion.In fact,in recent years,the academic community also advocates paying attention to the modesty of the preference protection for the consumer.Because too much preconceived preference protection will increase the "potential operating costs" of the operator,and the final feedback will be on the bearer of the price,namely the consumer.This runs counter to the consumer protection.This is also applicable in the protection of insurance consumers.In the judicial practice of serious illness insurance,the judges mostly use the backward logic of the conclusion,with the purpose of giving preference to the protection of the insurer and the insured,and strictly enforce the responsibility of the insurer.This is contrary to the equity,not conducive to the healthy development of the insurance industry,and also deviates from the original intention of protecting the insurance consumers.Based on this,this paper conducts an in-depth analysis of the problems discovered in the above cases,and puts forward perfect suggestions adhering to the concept of protecting the interests of the serious illness insurance consumer groups.In terms of the obligation of truthful disclosure of the insurer:First,unify the standards for the obligation of truthful disclosure of the insurer of serious illness insurance,subjectively divide and identify the boundary of "deliberate" and "gross negligence",and objectively expand the existing content of the standard of causality.Second,expand the scope of the subject of the obligation to truthfully inform,and the insured should also be the subject of the obligation.Third,clarify the secondary notification of the complex effect of the insurance contract.In terms of the insurer’s obligation to explain the exemption clause:First,the interpretation method of the intermediate position is used to explain the exemption clause,which can avoid the disadvantages of the legal functionalism in the past.Second,the performance standard is determined from the formal standard and the substantive standard,and the unified judgement scale.Third,the use of adverse interpretation rules is regulated.When dealing with the standard clauses,the general interpretation should be carried out according to the provisions of Article 142 and Article 466 of the Civil Code.Only when the general interpretation rule can not clearly define the specific meaning can the adverse interpretation rule be applied.更多还原