保险期间内发病、期外确诊 重疾险能不能赔？

Core Viewpoint - The case highlights the complexities and potential disputes in insurance claims related to critical illness, particularly regarding the timing of diagnosis and the interpretation of insurance contract terms [1][5]. Group 1: Case Summary - A court in Guangxi Province ruled that an insurance company must pay 100,000 yuan for a critical illness claim, emphasizing the importance of clarifying the insurance responsibility period and claim conditions [1][5]. - The insured, Wang Fang, was diagnosed with amyotrophic lateral sclerosis (ALS) two months after the insurance policy expired, but symptoms had developed during the coverage period [1][3]. Group 2: Legal Reasoning - The court determined that the onset of the illness occurred during the insurance period, despite the diagnosis being made after the policy expired, thus falling within the insurance company's responsibility [3][4]. - The court found that the insurance company's strict definitions of critical illness and the failure to adequately inform the insured about these terms rendered the exclusion clauses ineffective [4][6]. Group 3: Industry Implications - Experts noted that the time gap between the onset of symptoms and diagnosis is common in critical illness cases, and insurance companies should not use this delay to avoid liability [5][6]. - Insurance companies are advised to design clear and fair contract terms, define the trigger points for insurance claims, and fulfill their obligation to explain these terms to policyholders [6].