[accidents] man is not a safety rope fall injury insurance company refused to pay

Qianmou accidentally fell and injured when working at heights. The insurance company refused to pay the money on the ground that the money was not tied to the safety rope.

On the 4th, the City Intermediate People's Court made a final judgment, the defendant insurance company did not give the insured person a prompt and clearly stated obligations for the exemption clause. The exemption clause did not have legal effect, and the verdict insurance company indemnified Qianmou insurance totaling more than 230,000 yuan.

On September 30, 2014, Qian's company insured 83 employees for a group accidental injury insurance and additional group accidental injury medical and hospitalization allowance insurance to an insurance company in Nantong.

Among them, Article 5 of the "Special Proposal List" states:

When the insured engages in work at heights, it must carry out work activities in accordance with relevant industry safety management regulations (including but not limited to the need to wear safety ropes, safety belts, or installation of safety nets, etc.), otherwise the insurance company may suffer personal injury or death. And medical expenses are not liable for compensation. However, the "special agreement list" only covered the special seal for insurance of the defendant insurance company, and it was not sealed by the insurance company and signed by the insured.

On July 15th, 2015, when Qianmou was working on a steel structure in a Suzhou project undertaken by his company, he accidentally dropped an injury from the scaffolding, resulting in an eighth-grade disability. This was recognized as a work-related injury by the Municipal People's Bureau.

In October of the following year, when the insurance company investigated the accidental injury accident happened to Qianmou, Qian did not have a safety rope when working. When Qian Yu proposed a claim, the insurance company did not comply with the industry safety management regulations. The safety ropes were not tied up to carry out operations, and they belonged to the “detailed list” in accordance with Article 5, and refused to pay.

Qianmou filed a lawsuit in the Tongzhou District Court, demanding compensation for the main accident insurance premium of 180,000 yuan, medical insurance fund of 50,000 yuan, and hospitalization allowance insurance fund of 5,280 yuan, for a total of 235,280,000 yuan.

In the courtroom, Qian argued that the special agreement was not known and that the clause was not in effect; the insurance company argued that the plaintiff, as a steel structure worker, had stipulated the relevant safety operations in the “special agreement list” of the insurance contract. It should be understood that the exemption in this special agreement will have effect in accordance with the law.

Tongzhou Court held that:

The text in the “Special Prompt List” involved in the case was not bolded or darkened. There is no difference in the size and color of the other terms of the insurance clause. The defendant insurance company can be deemed as not fulfilling the duty of exemption clause; and the insurance policy “ The special insurance agreement and the “special agreement list” have not been signed or sealed by the insured company. The defendant insurance company can be deemed to have failed to perform the express obligation of the exemption clause. Therefore, the clause has no legal effect.

According to the contract of the insurance contract, personal accidental injury happened in Qianmou is covered by the defendant's insurance company. During the insurance period, the insurance company incurred a loss due to an insurance accident. The insurance company of the defendant should bear the insurance liability according to the compensation standard stated in the insurance contract. Since the defendant’s insurance company had no objection to the insurance amount of 235,280 yuan for the main insurance and additional insurance calculated by Qian, the insurer decided that the insurance company would make compensation according to this amount to Qian.

The insurance company dissatisfied and considered that the hazards of not carrying out safety measures at work at high altitude were known to the public. They did not need to be further clarified and appealed to the court of second instance. The City Intermediate People's Court upheld the original verdict.

â–  Judge argument â– 

The four contractual obligations that the insurer should bear

Liu Xi, the second instance adjudicator of the case, said that Article 17 of the “PRC Insurance Law” stipulates: “If an insurance contract is entered into and the format provisions provided by the insurer are adopted, the insurance policy provided by the insurer to the applicant shall be accompanied by a form clause. The insurer should explain the contents of the contract to the insurant, and when exempting the insurer from liability in the insurance contract, the insurer should make a notice on the insured policy, insurance policy, or other insurance certificate sufficient to attract the insured's attention when signing the contract, and The contents of the clause are clearly stated in written or verbal form to the policyholder; if no hint is made or it is explicitly stated, this clause will not produce any effect." The exemption clause in the insurance contract is a typical form clause. According to the above regulations, the insurer shall When the formal terms provided by the company form an insurance contract, it shall bear four contractual obligations such as the terms of the delivery form, the contents of the contract, the clauses exempting the insurer from liability in the format clause of the policyholder, and the exemption clause clearly stated to the applicant.

Liu Ye said that in this case, the “special agreement list” was a typical exemption clause. It was not sealed by the insurance company or was signed by the applicant himself, and the defendant also had no evidence to prove the concept, content and law of the exemption clause. The consequences are clearly stated to the policyholder, so the clause does not have legal effect.