Case Introduction
Mr. Liu, who is in his twenties, has been troubled by an extraordinary weight since childhood, weighing over 300 pounds at its peak. Whether on a diet or exercising, his weight loss has been ineffective. In May 2022, Mr. Liu went to the hospital for treatment due to abnormal weight gain. After diagnosis, he was diagnosed with metabolic syndrome and needed to undergo gastric sleeve resection surgery for treatment.
Before seeking medical treatment, Mr. Liu had purchased medical insurance from an insurance company. However, after the surgery, Mr. Liu's application for compensation from the insurance company was rejected. The insurance company believes that Mr. Liu has a history of illness, with a weight gain of 20 years. If he had known that his medical history existed for a long time, according to the contract, his past illness is not covered by the insurance. Moreover, gastric sleeve resection is not a necessary medical treatment for metabolic syndrome. Mr. Liu's surgery is for cosmetic weight loss and plastic surgery, which falls under the exemption of medical insurance provisions.
Helpless, Mr. Liu filed a lawsuit with the Xicheng Court, demanding that the insurance company compensate more than 50000 yuan in insurance benefits according to the contract agreement.
Court Trial
After the trial by the Xicheng Court, it was found that Mr. Liu, as the policyholder, made an insurance claim to the insurance company, and the insurance company also reviewed and issued an insurance policy to Mr. Liu, establishing an insurance contract relationship between the two parties. A contract established in accordance with the law shall take effect from the time of its establishment. Mr. Liu underwent gastric sleeve resection surgery in the hospital after being diagnosed with metabolic syndrome. The two key issues in this case are whether Mr. Liu's metabolic syndrome belongs to a past condition and whether gastric sleeve resection surgery belongs to cosmetic surgery.
Firstly, according to the provisions of the insurance contract, the criterion for judging past symptoms is based on the diagnosis already made by the hospital. Although Mr. Liu's medical record in this case records "abnormal weight gain for 20 years", the insurance company did not submit evidence to prove that Mr. Liu was diagnosed with metabolic syndrome by the hospital before applying for insurance. Therefore, the court does not accept the opinion of the insurance company that Mr. Liu's illness belongs to past symptoms and is not covered by insurance. Secondly, whether gastric sleeve resection surgery belongs to cosmetic surgery, the court believes that obesity is a common physiological condition, but not all obesity reaches the level of metabolic syndrome. Gastric sleeve resection is a commonly used method for treating metabolic syndrome, not just a simple weight loss cosmetic surgery. Therefore, the court considers that the medical expenses incurred by Mr. Liu due to metabolic syndrome fall within the scope of insurance liability. Judge the insurance company to compensate Mr. Liu with over 50000 yuan in insurance benefits.
After the verdict was pronounced, neither party appealed, and the verdict has now come into effect.
Judicial interpretation
As a professional insurance institution, insurance companies should exercise the obligation of careful attention to the health status of the insured, and review and evaluate the actual health status of the insured before agreeing to underwriting. If the insurance company raises inquiries about the relevant situation, the policyholder should also truthfully inform them. Insurance contracts usually also stipulate some exemption clauses, which stipulate that the insurance company is not required to bear compensation liability. For these exemption clauses, insurance companies should accurately understand and grasp them. For those that do not fall under the exemption situation but fall within the scope of insurance compensation, they should actively fulfill their contractual obligations and timely compensate according to the insurance contract. In this case, the contract stipulates that the criterion for determining past symptoms is based on the diagnosis already made by the hospital. If the insurance company is unable to provide evidence to prove that the policyholder was diagnosed with metabolic syndrome by the hospital before applying for insurance, it cannot refuse compensation on the grounds of "past symptoms".
From a medical perspective, gastrectomy can reduce gastric volume and is indeed helpful for weight loss. But with the advancement of medical technology, gastrectomy has become a common method for treating metabolic syndrome. The purpose of medical institutions performing gastrectomy on patients is to treat their symptoms, not to lose weight. According to the definition of insurance contracts, beauty refers to various medical beauty treatments, which refer to the repair and reshaping of a person's appearance and various parts of the human body using surgery, drugs, medical equipment, and other traumatic or invasive medical techniques, including various fitness treatments such as nutrition, weight loss, weight gain, and increased costs. Therefore, the gastrectomy involved in this case is not simply a weight loss cosmetic surgery and cannot be simply classified as a cosmetic treatment project. Therefore, the claims of insurance companies have not been supported.
This article is reprinted from Xicheng Court, and we would like to express our gratitude.