I. Case Summary: Duan is a pilot for an airline. One day, he purchased a major illness insurance with additional pilot disability income loss insurance from R Insurance Company via his WeChat public account, with a premium of 4,459 yuan, and the insurance period was from December 21, 2019 to December 20, 2020. When applying for insurance, Duan clearly informed R Insurance Company on the insurance page that he had severe myopia and uploaded a Level 1 medical examination certificate. Immediately, R Insurance Company passed the review and issued the policy. In May 2020, due to a slow decline in his eyesight, Duan was recommended by the aviation medical office for laser surgery. During the recovery period, Duan was suspended from flying by the airline, and Duan then filed a claim against R Insurance Company to pay a total of 264,000.00 yuan under the additional pilot disability income loss insurance. After reviewing the claim materials, R Insurance Company issued a "Refusal Letter," stating: "According to the insurance terms, the insured is exempt from liability for accidental injuries, untreated diseases, or disabilities suffered before the effective of this contract (except for insured persons who pass the medical examination and may perform flight missions, except for insured individuals who had untreated diseases or disabilities before enrollment); The insured did not provide supporting evidence that the disease required treatment for the grounding, so the case cannot be compensated for the time being. Duan argued that he had truthfully informed his health condition when applying for insurance, and that R Insurance Company knew he had myopia, so R Insurance Company should pay the claim. Due to the deadlock, Duan filed a lawsuit with the Wuhou District People's Court in Chengdu, requesting the court to legally order R Insurance Company to pay him the insurance money. On July 13, 2020, the Wuhou District People's Court of Chengdu issued a first-instance judgment, dismissing all of Duan's claims.
II. Clauses involved
Article 2 of the "R Insurance Company Major Illness Insurance Additional Driver Disability Income Loss Insurance Clause": During the insurance period of this rider contract, the insurer shall bear the responsibility to pay insurance benefits as stipulated below:...... (2) If the insured suffers accidental injury or falls ill after ninety days after the insurance contract takes effect, the civil aviation authority will determine the temporary loss of flight capability during the insurance period. The insurer will pay the temporary loss of ability to fly insurance benefit calculated by multiplying the daily benefit for temporary loss of flight capability by the number of valid days of temporary grounding.
3. Courtroom Transcript & In-Depth Analysis
Review: Is the surgery chosen by oneself or regulated by the organization?
Original generation: This is the treatment method recommended by doctors.
Review: If the 5D standard is met, can surgery be performed and flight can still be achieved?
Original: If the 5D standard is met but no surgery is performed, after vision correction, under current standards, the medical examination should be possible. However, since the plaintiff has long-term monocular myopia, which affects flight ability and safety, the unit's aviation doctor recommends that Icomplete the surgery as soon as possible.
From this section, it is clear that, first, Duan's surgery was not performed by the institution's regulations but by the recommendation of the aviation doctor. Second, even if he did not have surgery, he could still pass the medical examination, which would not result in the cancellation of his Level 1 medical certificate. This aligns with the relevant regulations of the Flight Standards Department of the Civil Aviation Administration of China, titled "Medical Marking for Medical Examination and Identification of Air Crew and Air Traffic Controllers." Therefore, even if there is a connection between the disease and the surgery in this case, it does not change the fact that surgery was the immediate cause of the insurance event in question.
- The "surgery" was the immediate cause of this insurance event and is not within the scope of R Insurance Company's underwriting liability, so R Insurance Company is not obligated to pay insurance benefits
According to analysis, the insurance incident in this case was not caused by "illness" causing the civil aviation authority to determine loss of flight ability during the insurance period, but rather due to the "surgery" that caused the loss of flight ability. Therefore, this case does not fall within the scope of insurance liability.
- Insurance contracts have a nature of luck; if insurance compensation is paid in this case, the contract's risk of luck will be completely nullified (the court fully excerpted this view in the judgment)
The so-called 'lucky nature' of insurance contracts means that insurance contracts are opportunistic contracts. Whether the policyholder can receive insurance compensation after purchasing depends on whether the insured event occurs during the validity period of the contract, and the occurrence of this event is not subject to the will of the insured or the insurer. Specifically in this case, if Duan had made arrangements at the time of signing the insurance contract to perform surgery immediately after signing, then the insurance event stipulated in the contract would inevitably occur. Moreover, the occurrence of such an insurance event would entirely depend on whether the plaintiff intended to perform the surgery or when it would be performed, thereby nullifying the contract's effectiveness. Therefore, we believe the defendant should not claim insurance money from Duan in this case.