保險理賠糾紛之探討

Abstract

財團法人保險事業發展中心是在保險人與被保險人對於保單理賠產生糾紛時進行仲裁的調停機構，由各領域專業顧問群對於事件發生原因與過程進行研判，再與保單內容相互對應是否符合理賠要件以進行理賠糾紛的裁決。 根據行政院金融監督管理委員會100 年度保險申訴案件統計，人身保險每年申訴案件數約3500 件左右，其中大部分案例都是屬於發生原因認定不同之理賠爭議類型(約佔所有案件之90%)，在被保險人死亡之案件中我們發現不論是醫院開立之死亡證明、院外之行政相驗、或是司法相驗，在所有保險理賠糾紛案件中分別約佔三成、三成、四成，表示不管哪種方式的死亡證明其對於死亡方式的確定性都無法完全達到讓保險公司認同的標準，因此，如果能夠對目前現行較可能 因為缺乏參考死者過往病程及事發過程而對死亡方式導致誤判的行政相驗，及解剖率只有11%的司法相驗及解剖制度進行改進，除了能夠在刑事案件上幫助偵查及在法庭上有更有力之證據，亦可幫助一般社會大眾對於保險理賠正義之伸張。有保險理賠糾紛的司法相驗案件中有解剖者佔13件(22.8%)，但在這13件解剖案件中並無出現有做解剖鑑定而仍無法做出保險理賠鑑定意見之狀況，顯示解剖鑑定為大家所能接受最具確定性之鑑定方式。

The Taiwan Insurance Institude（TII）is an institude handling complaints and providing mediation services between insurance client and company .There are consultants from variety of territories judging the complaint event from insurance clients,so they could make a proper mediation for both sides of insurance complaint. Using 2011 statistical analysis of insurance appealing from Financial supervisory commission R.O.C. ,it is estimated that 3500 cases per year involving personal insurance disputes require mediation.Most cases(about 90%) are about the disagreement of both sides on the causation of insurance incidence.In some cases with dead insurance clients,no matter what the death certificates are issued from the doctors in hospitals,or in clinicians ,or medical examiners,they hold claim dispute about 30%,30% and 40% respectively,that means either death certificate origin can’t reach the confidence standard of insurance companies .Hence,if we could make more effort to improve the system of postmortem examination from the hospitals which are lacking the trust for shortening evidence of the dead and the judicatory death certificate prescribed by medical examiners with low autopsy rate,we could give a powerful hand on criminal investigation and evidence of criminal trial,besides,also help the public to pursue the justice in claim disputation.Among them,only 13 cases of autopsy were performed (22.8% of judicial postmortem examinations),but all autopsy cases conclusively identified the manner of death and resolved the insurance disputes. The results show forensic autopsy may be the only conclusive method in solving the disputations.