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Under what circumstances the insurance company refuses to pay

Under what circumstances the insurance company refuses to pay

Insurance does not guarantee insurance, nor does insurance guarantee compensation. Not all accidents are covered by insurance companies. The reasons why insurance companies deny claims generally include the following:

First, the insurance company shall not be liable for compensation beyond the scope of liability stipulated in the insurance contract. If the insured is insured with participating insurance and applies for compensation for hospitalization due to illness, but the insurance liability of this type of insurance does not include medical insurance, naturally no compensation will be paid.

Second, the insurance company may refuse to pay after the specified time limit. When the insurance accident occurs, whether the insurance contract is valid; whether it is within the exemption period (observation period); whether the claim is still within the time limit for claiming is directly related to whether the insurance company loses money. For example, the general long-term life insurance contract will clearly state that after the policy takes effect, the insurance company has a 180-day “waiver period” during which the insurance company will be exempt from claims.

Third, if the insurance contract is invalid because the insurance applicant still fails to pay the due premium after being urged to pay, the insurance company shall not be liable for compensation. In a personal insurance contract, the insurance contract becomes effective after the insured pays the first installment of the premium, and the insured must pay the premium on time thereafter. When the validity of the contract is suspended, the insurance company may refuse to pay for the insured accident that occurs during the period of validity of the contract.

Fourth, the indemnity amount of the insurance company is limited to the insured amount. For example, the total insurance amount of an insurance contract is 100,000 yuan, and the accumulated compensation in the past few times is 60,000 yuan. If an insurance claim occurs again, the maximum compensation amount of the insurance company is only 40,000 yuan, and the excess will be borne by the insured.

Fifth, if consumers do not tell the truth, the insurance company can refuse to pay. An insurance contract is a good faith contract, the insured should truthfully inform the relevant situation before entering into the contract, otherwise, the insurance company may refuse to pay after the accident. If the insured of major disease insurance concealed the history of hepatitis B before purchasing the insurance and was diagnosed with liver cancer more than a year later, the insurance company may refuse to pay.

It is particularly important to remind that when buying some health insurance and life insurance, many people verbally informed some medical history, but the salesman said they could not fill it in. As a result, they were later accused of “concealing” their medical condition, but there was no evidence to refute it, which eventually led to the refusal of compensation. . Since the law only recognizes the matters notified in the written record of the insurance contract, consumers should pay attention to the written evidence when applying for insurance.

Sixth, the insured accident is exempt from liability. The insurance contract has listed the items that will not be compensated in the liability exemption clause of the insurance contract, and the insurance company will not be compensated. For example, suicide within two years of insured, etc.

Seventh, the signed life insurance contract is invalid. An invalid insurance contract means that the contract has been concluded but has no legal effect. For example, a life insurance contract with death as a condition for payment of insurance benefits can be regarded as invalid without the written consent of the insured (except that the insured is a minor). The insurance company has the right to refuse compensation.

Eighth, lack of necessary claim documents and materials. After the insured is out of danger, the beneficiary shall promptly provide necessary documents and materials to prove whether it is an insurance liability accident.

Ninth, a small number of policyholders falsely report the insurance liability accident, exaggerating the extent of the loss of the insurance accident, the insurance company may refuse to pay after checking the facts.