被保险人郑某于2015年2月投保了保额20万元的重大疾病保险。2024年5月，郑某因急性主动脉夹层（Stanford B型）接受了胸主动脉腔内修补术，这是一种无需开胸的微创手术[1]。保险公司以手术未采取开胸或开腹方式为由，仅赔付4万元，拒绝支付剩余16万元重疾险[1]。
深圳龙岗法院认定，保险公司依据的免赔条款属于格式条款且不符合医学进步规律，判决该条款部分无效[1]。法院指出，重大疾病保险的本质是保障疾病本身，而非治疗方式，保险公司不能因被保险人选择更先进、更安全的治疗方式就拒绝承担保险责任[1]。最终法院判决保险公司向郑某支付剩余重大疾病保险金16万元，二审维持了原判[1]。
A Shenzhen court has invalidated an insurance company's condition that excluded coverage for critical illness claims when treatment did not involve chest or abdominal incisions, ordering the insurer to pay the remaining benefit to a policyholder who underwent minimally invasive surgery for acute aortic dissection.[1]
The dispute arose after Zheng, the insured, was diagnosed with acute aortic dissection (Stanford Type B) in May 2024 and underwent endovascular repair of the thoracic aorta—a minimally invasive procedure requiring no open surgery.[1] The policyholder held a critical illness insurance policy with a total coverage of 200,000 yuan, purchased in February 2015.[1] The insurance company paid only 40,000 yuan, representing 20 percent of the basic insurance amount, and refused to cover the remaining 160,000 yuan in critical illness benefits on the grounds that the surgery had not involved opening the chest or abdomen.[1]
Zheng filed suit seeking the unpaid 160,000 yuan.[1] The Shenzhen Longgang District People's Court determined that the insurance company's contractual clause limiting coverage based on surgical method constituted an unenforceable exemption clause inconsistent with medical advancement, and rendered the clause partially invalid.[1] The court ordered the insurer to pay the remaining 160,000 yuan in critical illness insurance benefits, and the decision was upheld on appeal.[1] The court reasoned that critical illness insurance fundamentally protects against the disease itself rather than the method of treatment, and that an insurer cannot deny coverage simply because the insured chose a more advanced and safer therapeutic approach.[1]
