寿险理赔智者说—关于违反法律除外责任的判例|违法和保险理赔

从今天开始,我们会陆续刊出多位寿险大咖,特别是理赔界泰斗级人物的文章或者观点,以飨读者。

本文作者为MunSumKok(马来西亚),分别在马来西亚、香港、中国大陆(信诚人寿等)从业多年,现已退休,但仍笔耕不辍,为后来者分享理赔知识的盛宴。

中文译者:Ethan LU,国内寿险资深两核人士,北美理赔师、北美高级寿险管理师(FLMI)

本文讲述关于违反法律的除外责任条款的解读,共两个部分,今天是第一部分。

文章3600字,读完约需要10分钟。

I have often said that I consider claims administration to be the most importance of the insurance functions, because this is where we see how professional an insurer is: is it trying its best to fulfill the promises made to its customers by looking at how it can pay a claim – or is it just interested in looking at ways to deny a claim, to ensure that claims do not eat into its profitability? This is indeed the classic moment when the rubber hits the road.

In my time in the AIA claims committee, from 1979 to 1994, I can honestly say that the claims deliberations have been a very non-partisan one, where the primary concern is asking the question: is this a genuine claim? We will look at both sides of the coin before we make a final decision that is very fair and equitable to all parties. If anything, I would say we often ended up taking the policyholders’ side more than the insurer’s side.

Since my retirement in 2003, I do have occasions to be acquainted with a number of claim decisions, some of which I have previously detailed in past issues. But these cases often related to one or two specific insurers because of my previous relationship with them. Are their standards of claims administration reflective of the entire industry?

我经常说,我认为理赔管理是保险职能中最重要的一项,因为这就是我们看到保险公司有多专业的地方:它是在尽最大努力履行向客户做出的承诺,看它如何支付理赔,还是只想看如何拒绝理赔、以确保理赔款不影响其盈利能力吗?这的确是橡胶上路的经典时刻。

我在友邦保险理赔委员会任职期间,从1979年到1994年,我可以诚实地说,理赔审议一直是一个非常无党派的审议,其中主要关注的问题是:这是一个真实的理赔吗?在我们做出对各方都非常公平和公正的最终决定之前,我们将研究硬币的两面。如果有什么不同的话,我会说,我们最终往往更多地站在投保人一边,而不是保险公司一边。

自从我在2003年退休以来,我确实有机会熟悉一些理赔决定,其中一些我以前在过去的问题中已经详细介绍过。但这些案件往往涉及一个或两个特定的保险公司,因为我以前与他们的关系。他们的理赔管理标准是否反映了整个行业?

To answer this question, I resolved to go into the case archives of the Ombudsman Financial Services, Malaysia from 2013 to 2019 as well as the Insurance Complaints Bureau, Hong Kong from 2005 to 2019. I will spend the new few issues to review the cases referred to both these mediation services for adjudication. I have looked at specific topics that seem to surface quite commonly both in Malaysia and Hong Kong.

At this point, I would like to stipulate a caveat: my comments refer my personal views as I see it and if I am sometimes critical of the decisions, it is not with a view of being disrespectful of either the OFS or the ICB as the case may be, although I may not be able to avoid creating this impression.

In this issue, I will concentrate on the question of what constitutes a “violation of the law”, an exclusion that is usually embedded in the Accident Insurance policies. My immediate sense is that insurers in Malaysia and Hong Kong were either not clear as to the intention of the wordings, or if they were, then they had acted in bad faith.

To aid me in researching this question, I have to dust off the dust from two textbooks, namely “Life and Health Insurance Law” by Muriel L Crawford, and “Anderson on Life Insurance” by Buist M Anderson.

为了回答这个问题,我决定从2013到2019进入马来西亚OFS(注:Ombudsman for Financial Services,金融服务监察员)的案卷档案,从2005到2019到香港ICB(注:The Insurance Complaints Bureau,保险投诉局)。我将用新的几篇文章来审查提交这两个调解机构裁决的案件。我已经看了一些在马来西亚和香港都很常见的具体话题。

在这一点上,我想做一个警告:我的评论是指我个人的观点,因为我看到它,如果我有时批评的决定,这不是一个不尊重人的观点,无论是OFS或ICB视情况而定,虽然我可能无法避免造成这种印象。

在这个问题上,我将集中讨论什么构成“违反法律”的问题,这是一种通常包含在意外意外保险单中的例外情况。我现在的感觉是,马来西亚和香港的保险公司对措辞的意图并不清楚,或者如果他们是,那么他们的行为是不诚信的。

为了帮助我研究这个问题,我不得不掸掉两本教科书上的灰尘,即穆里尔L克劳福德的《人寿和健康保险法》和布伊斯特M安德森的《安德森论人寿保险》。

Introduction

Malaysian accident insurance policies contain this exclusionary wordings:

“We will not pay benefits due to or expenses incurred for violation of law”

The Hong Kong Accident policies contain this exclusionary wordings:

“the insurer shall not cover any accidental benefit in respect of ‘violation or attempted violation of the law”.

But what exactly is meant by the phrase “violation of the law”? There were no attempts to define this phrase in the accident policies of both countries but from the actual cases in disputes, the insurers’ interpretation is to consider even minor infarction of the law to be exclusionary.

介绍

马来西亚意外险保单包含以下除外条款:

“我们将不支付因违法而产生的利益或费用”

香港的意外保单包含了这些除外性的措辞:

“保险公司不得承保与‘违反或企图违反法律’有关的任何意外利益”。

但“违法”一词究竟是什么意思?在两国的意外保险单中都没有对这一短语进行界定,但从实际纠纷案例来看,保险公司的解释是认为即使是轻微的法律冲突也是除外性的。

I have written about this topic in issue 34, and I will reproduce the relevant portion here:

In the mid-1980s, I was asked by a colleague as to whether jay-walking can be considered a crime and therefore a claim deniable under the exclusion clause for “violation of a law”. My reply then was that jay-walking is not a crime, but rather is an infarction of a municipal code and therefore be subjected to a fine if caught.

Infarctions are usually considered as very minor offenses punishable by fines but not by jail sentences nor by it being captured on a criminal record. Driving with an expired driving license or an expired road tax is considered an infarction. So is smoking in a non-smoking area. Although it can be argued that smoking in public areas is against public policy on the basis that secondary smoke is harmful to stander-by, and thus should be a misdemeanour.

Then there are misdemeanours, which is a higher level up. Misdemeanours may be considered a crime subjected to both a fine and a short jail sentence.

Finally there is a crime. In the US of A, a crime is defined as any offense punishable by a jail sentence greater than one year in length.

我已经在第34期中写到了这个话题,我将在这里复述相关部分:

上世纪80年代中期,一位同事问我,横穿马路是否可以被视为一种犯罪,因此根据“违反法律”的除外条款,这是一种可以否认的主张。

我当时的回答是,横穿马路不是犯罪,而是违反了市政法规,因此如果被抓住,将被处以罚款。

违规通常被认为是非常轻微的罪行,可处以罚款,但不是监禁,也不是犯罪记录在案。驾驶执照过期或道路税过期的车辆将被视为违规。在无烟区吸烟也是如此。尽管可以说,在公共场所吸烟是违反公共政策的,因为吸二手烟对旁观者有害,因此应该是一种轻罪。

然后是轻罪,这是一个更高的层次。轻罪可被视为犯罪,可同时处以罚款和短期监禁。

最后是犯罪。在美国,犯罪被定义为任何可被判处一年以上监禁的罪行。

But going through the above, I realized that I was not being sufficiently definitive. Can an insurer thus deny a claim resulting from the commission of a misdemeanour? Simply stated, law can be categorized into Civil Law and Criminal Law. This is what Life and Health Insurance Law has to say about Civil and Criminal Law:

Civil Law is “the body of law which determines private rights and liabilities… Criminal Law… prohibits and punishes conduct causing harm to the public.”

A crime is usually either a felony or a misdemeanour. A felony is a serious crime (e.g., physical assault, robbery, kidnapping, homicide or murder), for which the punishment can be imprisonment in a state or federal penitentiary, or even death. A misdemeanour is a lesser crime, usually punishable by fine or by imprisonment in a facility other than a penitentiary, such as a county jail.

In deciding what constitutes “violation of a crime”, we need to first understand what is the insurer’s intention in wording this phrase into the exclusion clause. Unfortunately, there is no definition of the phrase in all the insurance policies. In the US, it has been decided that this phrase is intended to exclude claims arising mainly from felonies, after a number of litigations.

In fact, the wordings in US policies are now very specific as to exclude only acts of felonies.

但是通过以上这些,我意识到我还不够明确。保险公司能否因此拒绝因轻罪而提出的理赔?简单地说,法律可以分为民法和刑法。这就是人寿和健康保险法对民法和刑法的解释:

民法是“决定私人权利和责任的法律体系……刑法……禁止和惩罚对公众造成伤害的行为。”

犯罪通常不是重罪就是轻罪。重罪是一种严重的犯罪(例如,人身攻击、抢劫、绑架、杀人或谋杀),其惩罚可以是在州或联邦监狱中监禁,甚至是死刑。轻罪是一种较轻的罪行,通常可处以罚款或监禁在监狱以外的设施,如基层监狱。

在决定什么构成“违反犯罪”时,我们首先需要了解保险公司在将这一短语写入除外条款时的意图。不幸的是,在所有的保险单中都没有这个短语的定义。在美国,人们已经决定,这个短语是为了除外主要由重罪引起的理赔,经过一系列诉讼。

事实上,美国保单中的措辞现在非常具体,只除外重罪行为。

But prior to this change, there were two different intentions which have been termed the status clause and the result clause respectively. The status clause is phrased to exclude coverage “while” the insured is violating the law. The result clause is phrased to exclude coverage “resulting” from violation of the law. Clearly, these two wordings have different results and can be confusing to policy owners, for whom the policy is written for.

The status clause is in play when an insured is injured in the act of committing a crime, such as being shot while robbing a home or a person. But if the act has been completed, and the insured is on his escape from the scene of the crime, violated a red light and is chased and injured by police, the insurer is liable to pay for such injuries under the status clause. On the other hand, employing the result clause, the claim would be denied. I did say that this distinction is rather confusing and is revelled only by lawyers having a field day with the fine distinction of word plays.

Now, let’s look at a US case where the insured stated that she will jump out of the car while it is moving. She did do so, injuring her head in the process. Is this a crime? By the definition above, she is not causing any harm to others – only to herself. So her claim would have been payable except that the court ruled that there is the concept of foreseeability – i.e., that a person should be able to prudently foresee that an injury may result from an un-prudent, harmful action. Thus her claim was denied that she had intentionally caused self-inflicted injury, which is also an excluded event in all accidental policies.

To be continued in part 2 where we will review some actual cases adjudicated by OFS in Malaysia, and by ICB in HK.

但在这一变化之前,有两种不同的意图,分别被称为状态条款和结果条款。状态条款的措辞是除外保险范围“当(while)”被保险人是违反法律的。结果条款的措辞除外了因违法而“导致(resulting)”的保险范围。

显然,这两个词有不同的结果,可能会让保单持有人感到困惑,因为保单是为他们编写的。

当被保险人在犯罪行为中受伤,例如在抢劫房屋或人时被枪杀时,状态条款就起作用了。但是,如果行为已经完成,被保险人正在逃离犯罪现场,闯红灯,被警察追赶和伤害,保险公司有责任根据状态条款赔偿此类伤害。另一方面,如果使用结果条款,理赔将被驳回。

我确实说过,这种区别是相当令人困惑的,只有律师们在一天的工作中才对文字游戏的细微区别感到高兴。

现在,让我们看看美国的一个案例,在这个案例中,被保险人说她会在汽车行驶时跳下车。她这样做了,在这个过程中头部受伤。这是犯罪吗?根据上面的定义,她不会对他人造成任何伤害——只会对自己造成伤害。因此,她的理赔本来是可以支付的,除非法院裁定存在可预见性的概念,即一个人应该能够审慎地预见一项不谨慎的有害行为可能导致的损害。因此,她的理赔被驳回,即她故意造成自残,这也是所有意外保险中除外的事件。

在第二部分中,我们将回顾一些由马来西亚的OFS和香港的ICB的实际判决案例。

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