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2021-06-17
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防疫保單銷售破百萬張 契約隱含未來理賠爭議
呼籲金管會邀集業者共商解決之道

國內新型冠狀病毒(2019-nCoV)疫情持續升溫,全台防疫保單的銷售情形成正比。金融監督管理委員會保險局統計,截至今年5月17日為止,整體產險業防疫保單新契約件數達289萬件,光是5月13日到19日,就新增了53萬張新契約保單,如以一人投保一張保單計算,全台達12.6%的人口購買防疫保單,光是保費收入就超過13億元,而完成理賠的件數則為658件。

市售的法定傳染病防疫保單,由於保費便宜、理賠規則簡單,成為保險市場的熱銷商品,但隨著疫情增溫,最近一週的每日確診人數遽增,加上少數醫院爆發院內群聚或確診案例,加大衝擊醫療量能的力道,中央流行疫情指揮中心緊急宣布症狀分流的醫療降載措施,避免醫療資源大崩潰,預計未來將出現輕症及無症狀的確診被保險者受到醫療資源的排擠,連帶影響其醫療保險理賠權益,對此,目前尚無保險公司公開表態或發言,而主管保險業務的金融保險委員會保險局亦未展開關切,現行業者銷售的防疫保單,未來將暗藏重大的理賠爭議可能性。

為此,本會近期抽樣檢視國內八份以防疫為訴求保險商品,並參考香港及新加坡的疫情保單條款後,針對保障內容、理賠規定進行檢視,是否有損及保險消費者的權益之處,除呼籲主管機關應邀集業者研究解決之道外,並提醒消費者投保前應預先檢視契約,避免影響自身投保權益。

本次抽樣保單來自四家壽險公司及四家產險公司推出的防疫保單,共計八張保險商品,包含如下(調查期間:2021年5月17日到5月23日):

  1. 「國泰人壽-心安逸一年定期住院日額健康保險」、
  2. 「南山人壽-日溢幸福住院日額健康保險」、
  3. 「新光人壽-活力罩一年期住院日額健康保險」、
  4. 「台灣人壽365-一年定期住院日額健康保險」、
  5. 「富邦產險-疫起守護2.0(計畫一)」、
  6. 「旺旺友聯產險-疫應俱全專案(計畫B)」、
  7. 「兆豐產物-法定傳染病全民防疫專案(計畫A)」、
  8. 「新安東京海上產物-個人突發傷病健康保險-健康御守+(計畫A)」。

對於投保消費者的提醒:

一、每張保單的理賠(承保)範圍及理賠金額,各有不同

統計顯示,本次抽樣的八張防疫保單,大多以住院醫療保險金與負壓隔離病房保險金,搭配確診保險金或隔離保險金加以組合,保險期間皆約定一年,如需續保則需符合個別約定。

保險費率依性別、年齡各有不同(部分產險公司推出不分性別與年齡的同一費率商品),如以每日住院醫療保險金1,000元之商品組合試算,30歲男性保費介於529元~4,303元,30歲女性保費介於529~4,332元。

理賠試算,如以確診為新冠肺炎者,被醫院收治進行14天的住院治療(非負壓隔離病房)的情境試算,可請領的理賠金額最低為14,000元,最高為72,000元。

防疫保單的保險項目如何選擇,與確診新冠肺炎機率相較,被匡列為居家隔離的風險較大,建議商品比較順序,以隔離補償保險金為先、其次是確診保險金加上住院日額保險金。

二、隔離補償金理賠,排除封城或封區

經檢視,抽樣的八張保單,僅有兩張保單提供法定傳染病的隔離費用補償,而按各該保單的保險契約規定,被保險人僅有在收到政府隔離通知書處分而在家或在指定之處所隔離或隔離治療者,始得申請。因此,目前大眾熱議的封城或封區狀態,雖然民眾同樣是在家隔離不能出門,但並不符合隔離補償金的請領條件。此外,也提醒消費者,保險契約亦約定,契約有效期間內,保險公司僅限對同一法定傳染病給付一次,因此建議宜注意續保的相關規定。

三、確診保險金,僅限請領一次

如被保險人經醫師診斷確定為罹患衛福部依《傳染病防治法》第三條規定所公告之傳染病名稱之法定傳染病者,可請領法定傳染病關懷保險金(確診保險金)。經檢視,抽樣的八張保單,有五張有提供本項保障,惟各該保單的保險契約約定,於契約有效期間內,對同一法定傳染病給付一次為限。此外,檢視也發現,「新安東京海上產物-個人突發傷病健康保險-健康御守+」的保險契約約定,如契約生效前30天內被保險人曾罹患同一法定傳染病,則無法請領理賠,消費者投保前應注意特殊條款。

醫療分流 住院保險金理賠亟具爭議

特別提醒的是,抽檢的八張防疫保單,雖然皆提供按日理賠的住院醫療保險金,其中有七張防疫保單亦提供重症患者所可能需要的負壓隔離病房醫療保險金,如經醫師診斷確診而必須轉入治療時,除可請領前述的住院醫療保險金,還可追加申請該項的理賠金,然隨著疫情快速變化,政府成立類似醫院的「專責收治/收容機構」,但此種過渡性質的「加強版集中檢疫所」、「加強版防疫專責旅館」等機構,執行確診者隔離、觀察、治療,但是這些「收治/收容機構」是否符合保險契約所指的「醫院」的定義?未來符合確診投保人可否申請住院醫療保險金理賠?恐將發生不少法理爭議!

台灣的中央流行疫情指揮中心鑒於醫療資源有限,既有醫院應以治療重症患者為主,以保全醫療量能,而依中央流行疫情指揮中心已公布最新的醫療降載措施,凡屬輕症、無症狀確診患者,將被安置於「加強版集中檢疫所」收治,台北市則是送至「加強版防疫專責旅館」,新北市政府除此之外,則是另再研擬興建「方艙醫院」以為因應。因此,未來勢必發生,新冠肺炎確診的被保險人,因屬輕症或無症狀,無法被「醫院」收治,而是被送至「加強版集中檢疫所」、「加強版防疫專責旅館」甚或是「方艙醫院」進行隔離與照顧,一旦被保險人進入上述機構接受治療或安置之後,能否符合申請住院醫療保險金的理賠規定,具有很大的疑義。

根據各家防疫保單保險契約記載條款,「醫院」定義為:依照《醫療法》規定領有開業執照並設有病房收治病人之公、私立及醫療法人醫院屬之;「住院」定義為: 經醫師診斷其疾病或傷害必須入住醫院,且正式辦理住院手續並確實在醫院接受診療者。而「加強版集中檢疫所」、「加強版防疫專責旅館」、「方艙醫院」的機構定義各自為何?確診的被保險人被收治或收容於上述機構中,是否即符合保險契約約定之「住院」(住入醫院)之定義?能否請領住院醫療保險金?這些爭議亟需金融監督管理委員會保險局趕緊介入處理。

根據在香港AIG美亞保險集團在香港所發行的類似保險「INDIVIDUAL PERSONAL ACCIDENTBENEFIT PROGRAM DAILY HOSPITAL INCOME BENEFIT」約定保險條款PART I – POLICY DEFINITIONS中,對於「醫院」的定義,係指:「

『醫院』是指具備以下所有條件的機構:

1. 擁有合法經營醫院的牌照(若該國家或政府法例需要醫院領有牌照);

2. 為受傷及患病病人提供留院治療及照顧;

3. 有合法註冊專業護士提供全日二十四小時的護理服務;

4. 任何時間均有一位或以上的註冊醫生駐診;

5. 設有系統性診斷程序及完善的外科手術設備;及

6. 非作為診所、護理、休養、靜養、戒酒、戒毒等或類似服務的醫療機構。」[1]

參考上述國外保單對於醫院一詞的定義,目前在台灣發行的保單,未來將不可避免發生「 經醫師診斷其因新冠肺炎而發生的疾病或傷害,因為依照政府指示/規定,而經收/收治於「加強版集中檢疫所」、「加強版防疫專責旅館」、「方艙醫院」的機構時,確診而被收容/收治的被保險人,可否依據保險契約,向保險公司請求理賠住院的給付之爭議。

其次,現行保單款中,台灣的保險業者中,雖另有提供「(住入)加護病房或燒燙傷病房保險金(含負壓隔離病房)3,000元/日」(國泰人壽)、「3.  加護病房暨燒燙傷中心暨負壓隔離病房醫療保險金2000元/日」(南山人壽)、「3.加護病房暨燒燙傷病房保險金 2,000元/日(含負壓隔離病房,兩者最高365日) 」(新光人壽)、「3. 特別病房保險金(含負壓隔離病房) 2,000元/日」(台灣人壽)、「4. 負壓隔離病房保險金 2,000元/日(最高60日)」(旺旺友聯產險)、「4. 法定傳染病負壓隔離病房或加護病房醫療保險金1,000元/日(最高45天)」(兆豐產險),以及「3.突發傷病加護病房或燒燙病房保險金2,000元/日(含負壓隔離病房,每一事故最高45天)」(新安東京海上產物)。

惟經本會調查發現,根據衛福部常務次長石崇良於今年5月16日於指揮中心記者會表示,盤點目前的醫療量能,全國負壓隔離病房數只有658床(註1)。此外,指揮中心於同月22日統計,全國累計3,139例確診個案中,嚴重肺炎至呼吸衰竭等重症患者占10%,重症者會到負壓隔離病房救治(註2)。根據此述的「全國負壓隔離病房數」統計,目前在台灣住院的重症被保險者須轉至負壓隔離病房,嚴重處於「受限病床滿載而無法轉入」之窘境,既屬如此,「負壓隔離病房保險金」的理賠設計,豈不形同「買得到、但無法享受」的夢幻保障!

因此,如以確診新冠肺炎達重症者而須轉入負壓隔離病房,進行平均一週治療的情境來計算,現有的醫療資源一年可提供的負壓隔離病床數僅為3萬4216床,以全台289萬張產險防疫保單,10%保戶約28.9萬人為重症患者需入住負壓隔離病房,共計要花費8.44年才能全部完成每案的治療,而防疫保單約定期間皆限一年,保戶獲得理賠的機率幾乎微乎其微!

本會呼籲,金管會保險局應儘速針對可預期的保險契約爭議,邀集業者共商解決之道,要求業者全面檢視與調整市售防疫保單契約未盡完備之處以及道德風險管控與保障合理性,以保障百萬保戶的保險權益。

呼籲

  1. 呼籲金融監督管理委員會應儘速針對可預見的住院醫療保險金及負壓隔離病房保險金理賠爭議,邀集保險公司共商解決之道,研議從寬認定的標準與理賠程序,以保障百萬保戶的保險權益。在尚未形成解決共識之前,應規範業者於商品簡介及廣告揭露資訊,提供消費者必要知悉的交易訊息。
  2. 新冠肺炎的流行期間,保險公司應考量醫療資源的有限縮減確診被保險者的療程完整性,應當減少防疫保單保費,或者提高保險保障內容,以彌補保險消費者的權益喪失。
  3. 針對防疫保單的法定傳染病隔離保險金排除封城、封區的理賠請領,業者應清楚揭露於商品簡介及廣告,讓消費者充分知悉,以正確行使交易。
  4. 投保防疫保單之前,建議先比較「隔離保險金」的理賠額度,其次建議確認已投保的醫療險,是否涵蓋法定傳染病以及額度是否足夠。如已有醫療險的消費者,可先比較「確診補償金」,再考量日額住院醫療保險金的給付,搭配自己原有的醫療險、適當擴充理賠額度;若本身未規劃其他醫療險,可以先比較的是「住院日額」理賠部分,轉嫁確診治療期間的經濟負擔。投保前,應詳細審閱保險契約,知悉除外條款,明確了解權益再行投保。

財團法人中華民國消費者文教基金會


[1] “Hospital” means an establishment, which meets all the following requirements:

1. holds a license as a hospital (if licensing is required in the state or governmental jurisdiction);

2. operates primarily for the reception, care and treatment of sick, ailing or injured persons as inpatients;

3. provides 24-hour a day nursing service by registered or graduated nurses;

4. has a staff of one (1) or more licensed Registered Medical Practitioner available at all times;

5. provides organized facilities for diagnosis and major surgical facilities; and

6. is not primarily a clinic, nursing, rest or convalescent home or similar establishment and is not,other than incidentally, a place for alcoholics or drug addicts.

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