■本报记者 聂国春 投保重疾险时称确诊即赔，确诊后却遭拒赔，理赔纠纷由此引发。北京市西城区人民法院近日发布的《涉重疾险纠纷审判白皮书（2021—2024）》（以下简 称《白皮书》）显示，2021年至2024年，西城区人民法院金融街人民法庭共审理涉重疾险类案件284件，案涉标的额达6256.88万元，案件数量呈逐年增长趋 势。 《白皮书》披露的典型案例显示，前期健康询问模糊、电子投保提示不足是引发理赔纠纷的重要原因。尽管《互联网保险业务监管办法》已于2020年发布实 施，但仍有部分保险业务未严格落实办法规定，存在的问题包括：未通过有效技术手段记录、保存主要业务过程，在纠纷中无法提供案涉保险回溯视频，难 以证明投保过程；投保人与被保险人并非同一主体时，对于健康告知等关系被保险人切身利益、决定保险人承保与否的关键信息未详细与被保险人核实；线 上投保存在被保险人电子签名由他人代签的情况，保险公司难以提交证据证明电子签名真实性。西城区人民法院认为，防范此类纠纷需要从投保源头着手。 概括性询问变相加重告知义务 "被保险人是否近一年有新发或以往既有以下症状？反复头痛或眩晕、晕厥、咯血、胸痛、原因不明发热……原因不明的包块、 ...

Core Viewpoint - The article highlights the challenges faced by insurance consumers in claiming critical illness insurance, particularly the common reasons for claim denials by insurance companies, which often revolve around the insured's failure to disclose health information accurately [1][15]. Group 1: Claim Denial Reasons - The majority of claim denials are based on similar reasons, primarily focusing on health inquiry processes, claims procedures, and the validity of exclusion clauses [15]. - The most common defense used by insurance companies is the assertion that the policyholder failed to fulfill their duty to disclose information truthfully [15]. Group 2: Court Rulings on Disclosure Obligations - Courts have ruled that vague or general inquiry clauses do not constitute a clear request for information, and failure to respond to such inquiries does not equate to a breach of the duty to disclose [4][18]. - In a specific case, the court found that the insurance company's general inquiry about "other bodily sensations or activity disorders" lacked clarity, leading to a ruling in favor of the policyholder [19]. Group 3: Specific Case Examples - In a case involving a policyholder who did not disclose a suspected condition of trigeminal neuralgia, the court ruled that the insurance company could not deny the claim based on vague inquiries [19]. - Another case demonstrated that even if a policyholder failed to disclose a history of hepatitis B, the insurance company was still required to pay out the claim as there was no causal link between the undisclosed condition and the claim [22][23]. - A third case clarified that the "two-year incontestability clause" applies from the date of the insurance incident, not the policy's inception, reinforcing the principle of utmost good faith in insurance contracts [25][27].

案例分析： 《保险法》第十六条："订立保险合同，保险人就保险标的或者被保险人的有关情况提出询问时，投保 人应当如实告知。投保人故意或者因重大过失未履行如实告知义务，足以影响保险公司决定是否同意承 保或者提高保险费率的，保险公司有权解除保险合同。"该条款明确在投保时，如实告知是保险消费者 应尽的义务。 风险提示： 案例简介： 平安人寿潍坊中心支公司提示：消费者在投保时要仔细阅读健康告知，根据事实如实填写询问内容，不 要因为内容繁琐或听信他人误导性宣传隐瞒不进行如实告知，为以后理赔埋下隐患，造成经济损失。 2021年12月，张先生通过保险公司代理人为自己投保了一份保额10万元的重疾保障产品，投保时健康告 知项目均无异常，保险公司按照标准体正常承保。2022年8月，张先生家人报案称张先生因意外身故并 向保险公司提交材料申请理赔身故保险金。经保险公司调查发现，张先生是因为多处器官衰竭身故，不 存在突发意外情况。经核实，其在2018年因为肝囊炎、肝硬化住院，但投保时并未如实告知给保险公 司，未告知内容与本次身故有直接联系，且足以影响保险公司投保时的核保决定，故保险公司理赔赔结 论。 ...