“非医保用药不赔”条款研究

发布时间：2018-11-03 17:21

【摘要】：“非医保用药不赔”条款在交强险和商业第三人责任险中较为常见,对该条款的性质与效力的认定,理论与实务界存在较大分歧。本文通过分析实务中的典型案例,归纳出实务中“非医保用药不赔”条款的争议焦点在于该条款的性质是绝对无效的免责条款还是需履行提示说明义务方可生效的免责条款抑或是一般合同条款。然后再对此争议焦点进行展开分析。论文的第一部分将论述三个典型案例的主要案情、当事人的争议焦点和不同法院的判决观点,旨在归纳实务界对“非医保用药不赔”条款的争议焦点。实务中,有法院认为该条款属于排除对方主要权利、免除自身责任的绝对无效条款,有法院认为该条款属于《保险法》上规定的履行提示说明义务方可生效的免责条款,也有法院认为该条款属于一般合同条款,应充分尊重当事人的意思自治。第二、三、四部分是本文的重点部分。在第二部分,首先指出司法实践中面临的定性分歧和立法缺失的困惑,揭示出“非医保条款不赔”条款研究的论点和实践价值。在第三部分,笔者从分析非医保用药不赔条款的内涵和免责条款的概念入手,认定该条款属于免责条款。在第四部分,笔者提出了具体判断该条款效力的方法,即先从条款分配的权利义务是否公平的角度进行实质考察,得出该条款不属于权益义务失衡的绝对无效条款的结论,在这一结论的基础上,再根据《保险法》以及相关司法解释对该条款进行程序判断,即判断保险人是否就该条款的概念、含义和法律后果等向投保人进行了告知和明确说明,如未履行告知和说明义务,则该条款不生效,如已合理履行提示说明义务,则该条款即产生法律效力。第五、第六部分是对论点的进一步思考。对非医保用药是否理赔这一问题进行剖析,可发现问题的背后实则蕴含着不同性质保险的功能差异和保险合同当事人的利益纠葛。为根本解决此类纠纷,笔者结合司法实践的有益经验,提出了创设一种承保非医保费用的附加险种、从时机和险种区分处理非医保用药费用的理赔以及建立健全医疗费用的司法鉴定制度的解决途径。
[Abstract]:The "non-medical insurance drug does not compensate" clause is more common in the traffic insurance and the commercial third party liability insurance. There are great differences between the theory and the practice on the nature and effectiveness of the clause. Through the analysis of typical cases in practice, It is concluded that the focus of the dispute in practice lies in whether the nature of the clause is an absolute invalid exemption clause, an exemption clause that needs to be performed to indicate the obligation to be effective or a general contract clause. Then the focus of the dispute is analyzed. The first part of the thesis will discuss the main facts of the three typical cases, the dispute focus of the parties and the judgment views of different courts, in order to sum up the controversy focus of the "non-medical insurance drug non-compensation" clause in the practical circles. In practice, a court considers this clause to be an absolutely invalid clause that excludes the main right of the other party and exempts itself from liability. Some courts consider this clause to be an exemption clause which is provided for in the Insurance Law to give effect to the obligation of presentation before it comes into effect. There is also a court that this clause is a general contract clause, should fully respect the autonomy of the parties. The second, third and fourth parts are the key parts of this paper. In the second part, the author points out the qualitative differences in judicial practice and the bewilderment of the lack of legislation, and reveals the argument and practical value of the research on the "non-medical insurance clause without compensation" clause. In the third part, the author begins with the analysis of the connotation of the non-medical insurance non-indemnity clause and the concept of the exemption clause, and concludes that this clause belongs to the exemption clause. In the fourth part, the author puts forward the specific method to judge the validity of the clause, that is, from the angle of whether the rights and obligations assigned by the clause are fair or not, the author draws the conclusion that the clause is not an absolutely invalid clause which does not belong to the imbalance of rights and obligations. On the basis of this conclusion, according to the Insurance Law and the relevant judicial interpretation, the article is judged by the procedure, that is, the insurer is informed and clearly explained to the policy holder about the concept, meaning and legal consequences of the clause. If the obligation of notification and explanation is not fulfilled, the provision shall not take effect and, if the obligation of presentation has been reasonably fulfilled, it shall have legal effect. Fifth, the sixth part is the further thinking to the argument. By analyzing the problem of whether non-medical insurance drugs can be used to settle claims, it can be found that the functional differences of different nature of insurance and the interests of the parties involved in insurance contracts exist behind the problems. In order to solve this kind of dispute fundamentally, combining with the beneficial experience of judicial practice, the author puts forward the creation of an additional insurance policy to underwrite the cost of non-medical insurance. This paper distinguishes between the opportunity and the insurance type to deal with the claim of the medical expense of non-medical insurance and to establish the solution of establishing and perfecting the judicial appraisal system of the medical expense.
【学位授予单位】：西南政法大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：D922.284

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