The Tainan Branch of the Taiwan High Court rendered the 104-Bao-Xian-Shang-9 Civil Decision of December 5, 2017 (hereinafter, the “Decision”), holding that after an insured is treated while the lesion has not disappeared and has relapsed, indemnification certainly cannot be claimed against the insurance company since this pertains to the relapse of an existing illness.
According to the facts underlying this Decision, the Appellant filed a complaint asserting as follows. He had obtained the insurance at issue from the Appellee’s company. Pursuant to the insurance contract, if the insured had to seek a hospitalized treatment or surgery according to a physician’s diagnosis during the term of the insurance contract, the insured could claim insurance for the hospitalization cost by the daily hospital stay benefit multiplied by the actual number of hospitalization days pursuant to the insurance policy. The Appellant was subsequently hospitalized for treatment due to lumbar disc protrusion with acute sciatica, lumbar radiculopathy, tuberculosis, hypertension, and right femoral head avascular necrosis. After his insurance claim was rejected, he filed a complaint to compel insurance payment.
According to the Decision, the Appellant had continuously sought medical attention due to symptoms of tuberculosis in 2004, 2010, 2011 and 2012 after the treatment of his tuberculosis was completed in 2001. In addition, he was confirmed to have contracted obsolete pulmonary tuberculosis when he sought medical treatment in 2012, which also proves that it was a relapse of an old illness. In addition, the so-called completion of pulmonary tuberculosis treatment refers to the completion of a medication period but tuberculosis lesions do not disappear after the completion of the treatment. It is only that the lesions become fibrotic or calcific lesions. Since the illness contracted by the Appellant during his hospitalization was a relapse of an old illness before the effective date of the insurance contract at issue, the Appellee was not obligated to make insurance indemnification, and the Appellant should have returned the insurance payment which had been made.
It was further concluded in this Decision that although the Appellant could claim insurance under the contract for the remaining days of hospitalization, still the Appellant had no further claim available after the claim was offset against the insurance payment which had been received and should be returned. Therefore, the Appellant’s appeal was rejected, and the decision against the Appellant was upheld.