The Study of Health Insurance Dispute Claims on Mental Illness and Suggestions

• Main Authors: HSU,YI-CHIEN, 徐翊茜
• Other Authors: 洪樹人
• Format: Others
• Language: zh-TW
• Published: 2019
• Online Access: http://ndltd.ncl.edu.tw/handle/57cu3p

碩士 === 東吳大學 === 法律學系 === 107 === What is “mental illness”? Is mental illness has any different meaning in medical, legal or insurance area? Furthermore, when mental illness and commercial health insurance come across, what kind of issue will show up and be commented? After that, how to balance the insurance company’s and the policyholder’s ground to deal with these difficult and complicated interpretation problems. This is the core of this study; commercial health insurance dispute claims on mental illness. Commercial health insurance was introduced to the market more than 50 years ago. It becomes far more important than before as the people have longer life expectancy and the population is ageing. The development of society and economy, the growth of national income, the pursuit of better quality of life, and the popularization of higher education, all raise demands of commercial health insurance. With rising awareness of consumer protection and the advancement of medical technology, the disputes concerning contractual interpretation of mental illness in commercial health insurance contracts are worthy to be explored. Thus, this study is based on the definition of the exclusion “mental illness” of the health insurance contract, and the change in the hospitalization treatment of mental illness, which will extend to the scope of claims, and may even evolve into litigation cases. Therefore, this study believes that it should define the terms such as mental illness listed in the exclusion, as well as the treatment methods, and determine the scope of claims covered to solve the disputes. In addition, this study explores the judgments of various courts and various trials on the disputes mentioned above, and summarize the similarities and differences between courts, then proposes to solve the disputes. All in all, the root cause for the major disputes arising with the mental illness in the commercial health insurance contract is that the contract clause lacks definition of mental illness. Therefore, the obvious solution should center on defining the term with enough clarity to reduce or prevent recurring disputes. In addition to, based on the recommendations in this study, I strongly hope to offer as a reference for insurance companies to draw up or revise the terms of the health insurance contract in the future; even moreover, I sincerely expect to provide for the official authorities (such as Insurance Bureau, The life Insurance Association) and other relevant government organizations (such as the Legislative Yuan, the Ministry of Health and Welfare, etc.) as reference materials, when there is any chance going to legislate or modify the law. To sum up, because of the unclear terms of the health insurance contract, there is a huge gap between the insurance companies and the policyholders; each party has its own cognition to understand the terms, that’s the main point why these disputes occurred. In order to avoid the disputes about the mental illness claims occurring continually, this study intended to find out the causes of the disputes, and summarized the conclusions and possible suggestions which are expected to smoothly reduce or even solve these disputes in the future.