The client had a 'combined personal insurance' contract with a large insurance company. He had recently undergone vitrectomy surgery but the company refused to pay for it because of an 'old illness'.
An eye surgery for a patient - Photo: eyemantra.in
Reflecting to Tuoi Tre Online , Mr. QTĐ. in Vinh Long said that in 2024, he signed a contract to use the "human insurance" service with a large insurance company, the insurance is valid from March 1, 2024 to March 1, 2025.
In early January 2025, he went to the hospital and was diagnosed with "left eye deviation", requiring treatment with vitrectomy surgery, the treatment cost more than 20 million VND.
After the surgery, he sent a letter with documents asking the company to pay the insurance money, but the company refused.
"The reason they gave was that 10 years ago, I had cataract surgery, which was a disease that had developed before signing the insurance contract. This new surgery is a 'repetition of the previous treatment (?)'. I am very upset because the insurance contract does not show these terms. I contacted the insurance to discuss it again, but they still insisted on saying the same thing," he said.
"At first, the company's consultants did not provide complete information and did not clearly explain which cases were not covered by insurance so that customers would know. Now, what should I do to ensure my rights?", Mr. D. wondered.
According to lawyer Tao Van Dung (Ho Chi Minh City Bar Association), according to regulations, insurance contracts must be made in writing. Evidence of concluding an insurance contract is the contract, insurance certificate, insurance application or other forms as prescribed by law. (Article 18 of the Law on Insurance Business) 08/2022/QH15 dated June 16, 2022).
Thus, the certificate that the insurance company provided to Mr. D. showed that a contract had been entered into between him and the insurance company.
Regarding responsibilities and legal consequences for violating the obligation to provide information:
- When concluding an insurance contract, the insurance company or branch of a foreign non-life insurance company is responsible for providing complete and accurate information related to the insurance contract and explaining the insurance terms and conditions to the insurance buyer.
The insurance buyer is responsible for providing complete and honest information related to the insured object to the insurance company or branch of a foreign non-life insurance company.
- In case an insurance enterprise or a branch of a foreign non-life insurance enterprise intentionally fails to fulfill its obligation to provide information or If the insured provides false information to enter into an insurance contract, the insured has the right to cancel the insurance contract and receive a refund of the insurance premium paid.
Insurance enterprises and branches of foreign non-life insurance enterprises must compensate for damages arising to the insurance buyer (if any) (Article 22 of the Law on Insurance Business). 08/2022/QH15 dated June 16, 2022).
According to the information provided by Mr. D., the signed contract is stated in accordance with the human insurance provisions issued with Decision 1420/2012/QD/TGĐ - BHBV dated May 9, 2012. However, the contract is not attached with this decision, so in form this contract lacks the content and enforcement provisions.
Meanwhile, the notice of non-acceptance of compensation stated the exclusions not covered by insurance as stipulated in Article 8, Clause 3, Decision 1420/2012/QD/TGĐ - BHBV dated May 9, 2012.
Thus, Mr. D's case has two situations:
- If when signing the insurance contract, the company has provided full information, explained the conditions and exclusions of insurance according to Decision 1420/2012/QD/TGĐ - BHBV dated May 9, 2012 and you are in the case specified in Article 8, Clause 3 of Decision 1420/2012/QD/TGĐ - BHBV dated May 9, 2012 (exclusions not covered by insurance), then you will not be paid insurance.
- If you have not been provided with full information, explanation of the conditions and exclusions of insurance in Decision 1420/2012/QD/TGĐ - BHBV dated May 9, 2012 or have requested the company to provide information in writing but the company has not responded to your request, then the company has violated its obligation to provide information.
Mr. D. can file a civil lawsuit with a competent court to request the cancellation of the insurance contract, request a refund of the insurance premium paid and compensation for damages.
Administrative sanctions:
Failure to provide full information and explain the conditions and exclusions of insurance by an insurance business will result in an administrative penalty with a fine of up to VND 100 million.
Remedial measures:
- Compulsory provision to the insurance buyer of documents during the conclusion of insurance contracts that have not expired at the time of discovery of the violation.
- Force the insurance buyer to clearly and fully explain to the insurance buyer the insurance benefits, insurance liability exclusion clauses, rights and obligations of the insurance buyer of insurance contracts that have not expired at the time of detecting the violation for the violation (Article 16 of Decree 174/2024/ND-CP dated December 30, 2024).
Source: https://tuoitre.vn/tu-choi-tra-bao-hiem-vi-benh-cu-phat-sinh-cong-ty-bao-hiem-co-choi-dung-luat-20250227181904474.htm
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