The Taichung Branch of the Taiwan High Court rendered the 106-Bao-Xian-Shang-Yi-Zi-7 Civil Decision of December 27, 2017 (hereinafter, the “Decision”), holding that except as otherwise specifically excluded from the cancer insurance contract, all medical treatment methods which are sufficient to achieve cancer treatment efficacy should be included in the medical treatment methods covered by the cancer insurance.
The facts underlying this Decision are as followed:The spouse of the Plaintiff (i.e., the insured) obtained life insurance with a permanent cancer insurance rider for the Plaintiff(hereinafter, the “Policy at Issue”) from the Defendant (i.e. the insurance company). The Policy at Issue stipulates that in case of radiation or chemotherapy, an insurance payment of NT$2,000 for treatment would be paid in each instance based on the actual number of treatments. The Plaintiff asserted that she went through a surgery for breast cancer and was subject to a total of 448 courses of hormone treatments with Tamoxofen. She asserted to the Defendant that theTamoxofenhormone treatments fell within the scope of “chemotherapy in a broad sense” and claimed insurance to the Defendant.However, she was rejected by the Defendant. She therefore brought this action in court to request insurance payment for the 448 courses of Tamoxofenhormonetreatments.
According to the Decision, although the professional medical consultants of the Financial Ombudsman Institution held different opinions concerning whether the hormone therapy using Tamoxofen was a chemotherapeutic method, still it could be confirmed that hormone therapy and traditional chemotherapy are interactivelysupplemental or substitutable. Hence the therapeutic effect of the hormone therapycould bedeemed equivalent to the effect of theconventional chemotherapy. In additional, under the principle of interpreting ambiguous clauses for an insurance contract,an interpretation favorable to the applicant or insured should be rendered. Therefore, except as otherwise specifically excluded from the insurance coverage in the insurance contract, any treatment methods sufficient to achieve the cancer treatment efficacy should be included. Accordingly, the Tamoxofenhormonetreatment should be included in the “chemotherapy” under the Policy at Issue;thus fall within the insurance coverage of the Policy at Issue.
However, it was further considered in this Decision based on therapeutic practices that the so-called “actual number of treatments” under the Policy at Issue should be based on “course of treatment” set by the physicians to determine the number of treatments in this case to maintain the balance of insurance considerations and reflect the principle of good faith. Since the 448 courses of the Tamoxofenhormone treatment claimed by the Plaintiff were equivalent to 9 courses of conventional chemotherapy, the Plaintiff could claim insurance payment from the Defendant only for 9 courses of treatment.