近年來，意外傷害一直是國人重大傷亡的主因之一，而每年商業保險中的傷害保險給付金額均高達一百億左右，顯示傷害保險有其社會保障功能，亦使傷害保險成為每人不可或缺的保單之一。然傷害保險中對於保險事故之認定、承保範圍之解釋、不保事項之界定等，均有因條款定義不明，屢屢出現各種理賠爭議。 本研究經由傷害保險理賠爭議申訴調處及訴訟案例，檢視壽險公司核保及理賠作業流程規範，並分析保險契約雙方當事人爭議之理由，探討條款內容文字，以提供保險公司改進核保理賠作業規定及條款解釋與修正之客觀建議，期能藉以提高理賠時效、降低申訴率，進而維護保戶權益，有效解決保險糾紛，提升壽險業之形象。 In recent years, unintentional injuries are the people has been one of the leading causes heavy casualties, and the annual insurance commercial insurance in the amount of damage up to 10 billion are about to show harm to the insurance function of their social security has also become a casualty insurance so that each can not be or lack of one of the policy. However, insurance injury insurance for the accident found that the interpretation of insurance coverage but not defined in such matters, are unknown because the definition of terms, frequently give rise to various claims disputes. In this study, injury insurance claims through mediation and litigation disputes complaint cases, to view life insurance companies underwriting and claims workflow specification, and analysis of insurance contracts of the parties dispute the reasons to explore the terms of language, in order to provide the insurance company claims to improve the operation of the nuclear security and the terms of an objective interpretation of the amended proposal, a view to settlement of claims in order to improve timeliness and reduce complaint rates, thereby safeguarding the interests of policy holders, effective settlement of insurance disputes, enhance the image of the life insurance industry
