傷害保險之高危險行為爭議案例研究

Abstract

以傷害保險承保範圍作為討論起點，「意外傷害」指因不可預料之意外事故而致人體上遭受傷害情形，如因車禍而造成腳踝骨折、外牆磁磚掉落砸到頭部受傷、打球地面溼滑跌倒而鼻骨斷裂等。因意外而致使身體傷亡層出不窮，但其意外之發生可分為，來自於被保險人、他人、自然界，或來自於被保險人本身時，須非為被保險人之故意自我傷害或自願受傷害，亦即須因被保險人過失所致，始足當之。而來自於他人之侵害、或自然界之侵害所致之身體損傷，對被保險人而言，係屬不可預料性質，亦即均屬意外。\n被保險人之高危險行為常被保險人歸為有其重大之過失，或以故意行為為由排除於承保範圍之外，或以有違最大善意原則而免除保險責任。被保險人之高危險行為造成意外事故發生之認定有無差別，保險人對其被保險人遭受意外傷害及其所致失能或死亡時，負給付保險金之責，有否對價衡平可言，而不違保險之本意。\n經尋找不同高危險性活動或被保險人因自己從事高危險行為的案例，造成保險人認定被保險人違反道德風險故意使保險事故發生，保險人得以被保險人故意行為而致損失發生，保險人不負賠償之責。因被保險人違反保險最重要的誠信原則，在實務上與法院判決的看法得否一致，如對於真實因重大過失而造成損失發生的被保險人是否未能公平對待而給予救濟，保險法未明確規範被保險人違反了重大過失法律上的效果，透過整理、歸納，更能清楚辨別重大過失與道德危險上的區別與差異。

Taking the coverage of personal accident insurance as the starting point for discussion, “accidental injury” refers to the situation of personal body injury caused by unforeseen accidents, such as ankle fractures caused by car accidents, external wall tiles falling and hitting the head injured, playing balls on the slippery ground and falling to nose bone fractured, etc. Even though the accidents that cause innumerable physical injuries or death, the causes of the occurrences of accident could be divided into many reasons. It may be attributed to the insured, third parties or nature. When it is attributed to the insured himself, the reasons for the bodily injury or death shall not be caused by the insured’s deliberate self-harm or voluntary injury. It means that the cause of reason for the insured’s bodily injury or death shall be attributed to, one and only, the negligence of the insured. On the contrary, the bodily injuries or death caused by third parties or natural disasters are unforeseeable to the insured and it shall be referred to the accidents.\nThe insured`s potentially hazardous activities or behaviors are often classified as being attributed to the insured’s gross negligence or deliberate acts which would be excluded from the coverage of personal accident insurance or exempted insurer’s liability from violating the principle of utmost good faith. If there is any difference when determining whether the reason is caused by an accident or insured’s potentially hazardous activities and/or behaviors? In addition, when the insurer is liable for paying insurance settlement and/or compensation to the insured’s accidental injury, disability or death, whether the consideration is satisfied or not? All of these shall not violate the principles of insurance.\nBy way of searching for the different potentially hazardous activities or cases, or the insured engaged in the potentially hazardous activities which convinced the insurer of moral hazard caused the accidents occurred intentionally and it leads to the insurer being not responsible for paying the settlement or compensation due to insured’s willful misconduct. It is because the insured violated the most important insurance principle of utmost good faith. In practical, insurance business decisions might not consistent with the judgments of courts. As a result, if the insureds who truly suffered losses caused by gross negligence and failed being treated fairly by insurers can be treated fairly and to give relief. Even more, the Insurance Law does not provide clearly the effects of laws for the insured`s violation of gross negligence, this thesis tries to make it clear to distinguish the differences of the effects of laws between the insured’s violation of gross negligence in law and the moral hazard in breaking the principle of utmost good faith.\nThis thesis is completed through the study method of induction and deduction by collecting court’s cases to case study for the differences to induct as numbers of different type of cases and make a deduction for identifying the differences between the insured’s violation of gross negligence in law and the moral hazard by intentionally breaking the principle of utmost good faith.