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with the development of medicine, there may be multiple diagnosis and treatment methods for some major diseases. faced with patients who purchase critical illness insurance, can insurance companies refuse to pay on the grounds that "the diagnosis and treatment method is not within the scope of the contract"? recently, the qingjiangpu district court of huai'an city, jiangsu province, concluded a contract dispute case caused by critical illness insurance payment and ordered the insurance company to pay 220,000 yuan in insurance money.

in 2019, mr. li purchased critical illness insurance for his daughter xiao li from a company. the insurance period was from 0:00 on april 30, 2019 to the end of the insurance life or until the occurrence of a termination insurance accident specified in the contract.

after that, xiao li frequently experienced involuntary body tremors and stiff hands. in 2020, after an eeg examination and clinical diagnosis at the hospital, she was diagnosed with epilepsy (generalized). the doctor believed that her condition was not suitable for surgery and recommended drug treatment to relieve the symptoms.

after his daughter was diagnosed, mr. li filed a claim with the insurance company. however, the insurance company said that xiao li did not undergo the examination items stipulated in the contract, nor did she undergo neurosurgery, and refused to pay the claim on the grounds that "the agreed conditions for serious illness payment were not met."

mr. li believed that the insured was diagnosed during the insurance period and did not improve after treatment. his condition was serious and fell within the scope of major illness. the insurer should pay the insurance amount according to the contract. he then sued the court, demanding that the insurance company pay a one-time insurance amount of 220,000 yuan.

the court found that the critical illness insurance contract signed by both parties had the following provisions regarding "severe epilepsy": the diagnosis must be made by a neurologist or pediatrician based on typical clinical symptoms and imaging examinations such as electroencephalogram (eeg) and computed tomography (ct), magnetic resonance imaging (mri), and positron emission tomography (pet); relevant medical records for more than 6 months must be provided to prove that the insured has recurrent tonic-clonic seizures or grand mal seizures that have not responded to drug treatment, and has undergone neurosurgery, etc.

in order to find out whether the examinations and surgeries involved in the clauses are necessary means of diagnosis and treatment, the court went to the neurology and pediatric departments of two local tertiary hospitals to investigate and learned that the diagnosis of epilepsy with existing medical technology can be confirmed through typical clinical symptoms and electroencephalograms. the "tomography, magnetic resonance imaging" mentioned in the contract are means to clarify the cause of the disease for subsequent treatment, but are not necessary for diagnosis. in addition, the vast majority of epilepsy diseases cannot be treated surgically. combined with the insured's current situation and medical records, it can be confirmed that it is severe epilepsy.

the court held that the definition of severe epilepsy in the clause in question greatly limited the scope of compensation for the disease, deviated from the general cognition and common diagnosis and treatment methods of the general public, and actually exempted or reduced the insurance liability of the insurer, and should be deemed as an exemption clause. the insurance law stipulates that insurance companies should make reminders sufficient to attract the attention of the insured on the application form, insurance policy or other vouchers for such clauses, and explain them to the insured. however, the contract in question only used this clause as an ordinary insurance clause, without highlighting it, and the insurance company did not provide the insured with an easy-to-understand explanation and explanation of the concept, content and legal consequences of the disease. based on this, the court held that the above-mentioned disease definition clause did not become part of the insurance contract and was not effective.

the court held that the insurance contract between the insured mr. li and the insurance company was valid, and that the insured mr. li suffered from generalized epilepsy during the insurance period and had the right to require the defendant to pay the insurance money according to the insurance amount in the contract in accordance with the contract. the court ruled that the insurance company should pay according to the contract.