傷害保險具有低保費與高保障的特色，近年來已成為國人風險轉移的工具與不可或缺的保單之一。自從民國90年開放產險得以主約方式經營傷害保險後，傷害保險經營也越漸激烈，消費者的選擇雖更加多樣化，然而傷害保險條款對意外事故的認定、除外責任的界定等，因條款的定義不明確，致保險理賠爭議屢見不鮮。 大多數的傷害保險理賠爭議，常因保戶對相關資訊取得不足、保險觀念的不足，故對意外傷害事故認知產生差異，對條款的解釋錯誤。傷害保險實務上最常見的爭議為意外事故原因為「意外」或「疾病」，二者之間該如何認定?此外，保險公司常限縮條款的承保範圍，並對除外責任免責事由未詳加舉證便予以主張，均為常導致傷害保險理賠爭議的原因。 本研究從國內外學說論述結合我國實務見解，並舉列較具代表性實務判決，進一步探討保戶與保險公司雙方主張，並分析比較法院之見解與個人具體建議，以期能提供相同爭議實務運作解決方案與借鏡，最後對主管機關、保險公司與保戶進行建議，並期能縮短保險公司與保戶在認知上的差異，降低申訴乃至訴訟之情形。 In Taiwan, with low premiums and high security feature, accident insurance has become an indispensable tool and one of policy for transferring from risk. Accident insurance business getting into intensive competition, since 2001 the property insurance companies was allowed to operate the accident insurance under master contract. Consumer choice more diverse, but the terms of accident insurance identification, definition of exclusion, etc., because of indefinable definition of terms commonly caused insurance claims disputes.
Most of the accident insurance claim disputations owing to lack of obtaining insufficient relevant information or insurance concept, the insured always has difference awareness of accidental injury or misunderstanding the interpretations of provisions. There is a common controversy over the cause of accident insurance as “an accident” or “a disease” and how to identify between these two? Besides, the insurance companies often limit the insurance coverage in provisions reduction, and exempted from exclusion without evidence in detail would not be advocated.
This research expounds on theory from domestic and foreign countries that combines with the opinion of practice in our country, simultaneously developed into more typical practice decision to further explore the claims between the policyholder and the insurance company. Analyzed the court’s opinion and compared specific recommendation for individual with expectation of offering a practical operation solution and learning model to the same controversy. Provided the suggestions to the authority, insurance company, and the insured. Eventually to shorten the cognitive differences and reduce complaints even litigation.