Law

Does concealing medical history lead to rejection of insurance claims, which is considered an exemption from insurance liability?

2025-08-06   

Honesty and credit are the basic principles of workplace communication and also the legal obligations that workers should abide by. However, some workers deliberately conceal important information in order to obtain job opportunities or related benefits, which may ultimately result in more losses than gains. Recently, the People's Court of Xinluo District, Longyan City, Fujian Province concluded an insurance claim dispute case caused by a worker concealing their medical history. The party involved, Fan, was rejected for violating the principle of good faith in the insurance claim. In July 2022, Fan joined a certain insurance company Longyan Branch as a life insurance consultant. When filling out the "New Employee Health Declaration", he checked "none" for the inquiry about whether he had suffered from epilepsy or other brain diseases in the past five years, and promised that the information was true. If there was any concealment, he was willing to take full responsibility. The following month, Fan's insurance professional qualification was registered under the name of Longyan Branch of a certain insurance company. In January 2023, the superior Fujian branch of the insurance company purchased "Livelihood Group Hospitalization Medical Insurance" for field employees, including Fan. The terms clearly stipulate that the insured's past medical conditions, diseases diagnosed during the waiting period but confirmed after the waiting period, etc. are within the scope of exemption. In July 2023, Fan was diagnosed with right-sided temporal lobe epilepsy and right-sided hippocampal sclerosis due to "recurrent episodes of unclear consciousness and limb twitching". The surgical treatment cost 82800 yuan. Subsequently, Fan applied for group insurance claims from his newly hired Longyan branch. However, after investigation by Longyan Branch, it was found that Fan had been hospitalized twice for epilepsy in 2014 and 2020. The hospitalization medical record in 2023 also recorded that he had undergone epilepsy related surgery 12 years ago. It is obvious that he deliberately concealed his medical history, which falls under the exemption situation of Fan's group insurance. Therefore, Fan's claim application was rejected. After multiple unsuccessful communications with Longyan Branch, Fan filed a lawsuit requesting Longyan Branch to pay him a hospitalization medical insurance compensation of 5000 yuan in accordance with the group insurance terms. After trial, the court found that the group medical insurance purchased by the superior Fujian branch of a certain insurance company for Fan and others has clearly included past medical conditions as an exemption scope. As a professional with insurance industry qualifications and familiar with business knowledge, Fan deliberately concealed his history of epilepsy when he joined, violating the principle of good faith, which led to a misunderstanding when Longyan Branch reported the insured person's information to him, and did not provide special explanations for his past symptoms. Based on the pathological correlation between temporal lobe epilepsy and hippocampal sclerosis, as well as Fan's previous medical history, this treatment falls under the category of exemption from liability. Therefore, his claim for compensation is not accepted. The reason for the refusal of compensation by a certain insurance company, Longyan Branch, is legitimate and well founded. The court rejected Fan's lawsuit request in accordance with relevant laws and regulations. After the first instance verdict, neither party appealed. The judgment has come into effect. The judge stated that according to Article 8 of the Labor Contract Law of the People's Republic of China, the employer has the right to know the basic information directly related to the employee and the labor contract, and the employee should truthfully explain it. This means that employees need to truthfully inform themselves of their situation before joining the company, so that the employer can determine whether to hire or purchase relevant insurance. In this case, Fan concealed his epilepsy history in order to obtain a job position, which led to a misjudgment when the company purchased group insurance. Ultimately, Fan had to bear the medical expenses on his own, and this lesson is worth warning. In practical work, employers often require employees to fill out personal resumes or employment statements, and promise that the information is true, otherwise they will bear corresponding legal consequences. Therefore, in addition to their physical condition, workers should also truthfully disclose important work-related information such as identity information, educational background, work experience, and qualifications, and should not have a mentality of taking chances and falsifying information. (New Society)

Edit:Wang Shu Ying Responsible editor:Li Jie

Source:PEOPLE'S COURT DAILY

Special statement: if the pictures and texts reproduced or quoted on this site infringe your legitimate rights and interests, please contact this site, and this site will correct and delete them in time. For copyright issues and website cooperation, please contact through outlook new era email:lwxsd@liaowanghn.com

Recommended Reading Change it

Links