本研究探討商業健康保險理賠之爭議，其中醫療科技的提升影響著保險制度，而醫療資源是否有效運用及是否因醫療資源的濫用而衍生健康險的理賠爭議。依據保險業人身保險理賠爭議案件類型及原因分析，進而探討保險理賠申訴率與客戶滿意度關係的探討，以及保險公司面臨理賠爭議處理與風險的控管。藉由本論文，針對日益增加之申訴件共同尋求保險業未來如何面對保險理賠爭議之適切作法。 本研究藉由個案之研究從中學習保險公司理賠面臨申訴案件之處理困難。由被保險人住院必要性認定爭議、醫療保險除外責任認定爭議、癌症保險承保範圍爭議問題之案例所發現的問題，提出改善的建議。有助於縮短保險公司與保戶間雙方的認知差異，改善健康險的理賠爭議，進而提供保險公司理賠爭議處理流程之改善建議，和對全面保單風險控管有所助益，以降低保戶至外部申訴及訴訟之請求，並對我國健康險之保險市場健全發展有所幫助。 This research discusses the dispute of commercial healthy insurance claims, among which the promotion of medical technology influences the insurance institution. While the dispute of healthy insurance claims is derived from medical resources can be applied effectively and the abuse of medical resources. According to the case categories and reason analysis of personal insurance claim controversy, to further discuss the relationship between the ratio of insurance claim appeal and the degree of client satisfaction and insurance companies encounter how to deal with claim dispute and control risks. To aim at mounting appeal cases to seek for appropriate ways while insurance companies face the controversy of insurance claim in the future. This research, among which learns that insurance companies face dealing difficulties of appeals by case study. From the insured is hospitalized the necessity to recognize the dispute, the medical insurance exception responsibility recognizes the dispute to Cancer insures the extent of guarantee dispute question, which find out some problems to propose ameliorative advice. It is conducive to shortening cognitive discrepancies between insurance companies and insurers, improving the controversy of healthy insurance claim, and providing ameliorative advice, the dealing procedure of claim dispute, to insurance companies. Additionally, it is really helpful to control and manage the risk of overall policy to lower the insurers’ demand of external appeals and litigation. Most importantly, it helps insurance companies to possess a sound development of healthy insurance market in our nation.
