The Supreme Court rendered the 107-Tai-Shang-Zi 336 Civil Decision of June 22, 2018 (hereinafter, the “Decision”), holding that if any covenant set forth in an insurance policy does not comply with the concept that full-day hospitalization and daytime or night-time hospitalization are both hospitalization under the Mental Health Law effective when the insurance contract is established, it is necessary to clarify if there is any violation; and in the event of doubt, an interpretation favorable to the insured shall be rendered.
According to the facts underlying this Decision, the Plaintiff filed a complaint alleging that the terms of the insurance policy at issue stipulated that the daily reimbursement for hospitalized treatment shall be NT$2,000. Since he showed signs of presenile dementia with melancholia and severe depression, he was advised by a doctor to be hospitalized in a daytime ward of the hospital for treatment after he was discharged from hospital. After an insurance claim filed to the Defendant was rejected, a complaint was filed to seek insurance benefits. After losing both the first instance and second instance trials, the Plaintiff was still dissatisfied and appealed to the third instance.
According to this Decision, Article 25 of the Mental Health Law before amendment provided that manners of psychiatric treatment include outpatient care, emergency care, full-day hospitalization, daytime or nighttime hospitalization, community rehabilitation and home care. Although Article 2, Subparagraph 7 of the insurance policy at issue stipulates that “the ‘hospitalization’ referred to in this Rider shall mean that the insured must be hospitalized for treatment according to a doctor’s diagnosis as a result of an illness or injury and has formally completed the hospitalization formalities and actually stayed in hospital for treatment,” it seems that this does not require that “hospitalization” is limited to 24 hour stay in hospital, staying overnight in hospital or “full-day hospitalization.” In this case, this is still open to the question of whether such contract did not meet the concept that full-day hospitalization and daytime or nighttime hospitalization are both hospitalization under the above Mental Health Law effective upon the execution of the contract at issue. Basically, an interpretation favorable to the insured should be rendered for further clarification.
It was further pointed out in this Decision that as a result of relevant symptoms that the Plaintiff showed after he was discharged from hospital, the doctor arranged for his stay in a daytime ward for rehabilitation treatment to prevent the aggravation of the symptoms. Therefore, it is not true that whether the daytime hospitalization did not meet the covenant of Article 2, Subparagraph 7 of the insurance policy at issue was not open to further exploration. Without detailed exploration, the original trial court was rash when it jumped to the conclusion that the “hospitalization” set forth in Article 2, Subparagraph 7 of the insurance policy at issue did not include the daytime hospitalization for psychiatric illnesses and rendered a decision against the Plaintiff. Therefore, the original decision was reversed and remanded.