China: 保险公司理赔迟延的认定标准?理赔迟延应承担何后果?

Last Updated: 24 June 2019
Article by Huang Huazhen
Most Read Contributor in China, July 2019

一、裁判概览

(一)案件基本情况

2013年5月23日,甘肃省公路建设管理集团有限公司(以下简称甘肃公路集团)向中华联合财产保险甘肃分公司(以下简称联合保险甘肃分公司)投保建筑工程一切险附加第三者责任险 [1],并签订《建筑工程一切险附加第三者责任险保险合同》,约定:保险项目为十堰至天水高速公路甘肃段项目ST02标段;施工总承包商为中铁十七局第一公司,投保人为甘肃公路集团;保险期间自2012年8月1日零时至2015年5月31日二十四时止;投保范围包括物质损失:特种危险类-地震、海啸41363.84万元,土建项目51204.80万元,总保险金额为92568.65万元和第三者责任赔偿限额和特别约定;免赔额中关于暴风、暴雨、洪水风险导致的损失,每次事故免赔额10万元或损失金额的14%。甘肃公路集团将上述保险索赔的权利转让给了中铁十七局第一公司。

2013年6月20日,涉案高速公路施工路段发生洪灾,联合保险甘肃分公司承保的1标段、2标段、4标段因在河道施工而受损。后联合保险甘肃分公司进行现场勘查,经双方协商1标段保险理赔338万元,4标段保险赔偿399万元并形成现场勘查记录,但关于2标段的损失确定并未达成一致,定损工作因此陷入困境。

2014年11月9日,联合保险甘肃分公司通过保险经纪公司和中铁十七局第一公司形成了2标段理赔会议纪要,确认2标段的损失项目为:19根钻孔桩、4个钢筋笼、承台2个、墩柱1个,便道便桥部分受损需提供证据(后期联合保险甘肃分公司复勘时便道便桥进行了修复),现场材料、施救费需提供证据。

本案中,在双方对保险事故的发生和保险责任的承担已经达成一致的前提下,其核心争议点在于:第一,中铁十七局第一公司认为联合保险甘肃分公司存在故意推脱、定损不及时、不予理赔的情形(从事实上,从事故发生到一审法院立案,期间已经经过了两年零三个月);第二,双方就定损范围和定损数额未能达成一致,联合保险甘肃分公司主张应当按照现场勘查记录和理赔会议纪要确定损失,中铁十七局第一公司主张的损失则超出前述两个文件所确定的数额。

(二)审理要览

1.申请人诉求

一审原告中铁十七局第一公司将联合保险甘肃分公司起诉至兰州铁路运输中级法院,请求判令:被告向原告支付保险赔偿金15209699元;被告向原告支付以15209699元为基数计算自2013年8月20日起至实际支付时止(按人民银行同期同类贷款利息)的迟延付款损失;本案鉴定费18.6万元由被告承担。

2.审理经过

本案经过一审、二审和再审程序。一审法院兰州铁路运输中级法院作出(2015)兰铁中民初字第40号民事判决,判决:被告联合保险甘肃分公司向原告中铁十七局第一公司给付保险赔偿金8168544.88元;被告向原告支付迟延付款损失(以4084272.44元为基数自2013年8月20日起至实际支付时止按中国人民银行同期同类贷款利率计算);驳回其他诉讼请求。

二审法院甘肃省高级人民法院作出(2017)甘民终124号判决,判决驳回双方上诉人的上诉请求,维持原判。

最高人民法院作出(2017)最高法民申5103号裁定:驳回中华联合财产保险股份有限公司甘肃分公司的再审申请。

二、争议焦点解读

【焦点】保险公司理赔不及时的判断标准是什么?未按时履行行行赔付义务是否应向被保险人支付延迟付款利息?

1.当事人观点

本案一审原告中铁十七局第一公司在原审中提交了其于2013年6月20日向联合保险甘肃分公司提交出险通知书及索赔资料等证据,已按照被告的要求提交了相关理赔资料。但原告多次向被告要求予以赔偿,被告以各种理由推脱不予理赔。

本案一审被告联合保险甘肃分公司认为,2013年6月20日是中铁十七局第一公司的出险时间 [2],不是申请理赔的时间,此种计算方式完全错误。且根据保险法第二十五条之规定,保险人"收到被保险人的赔偿或给付请求......"才负有先行赔付的义务。本案自事故发生后中铁十七局第一公司就损失项目和范围一直无法和联合保险甘肃分公司达成一致,即便是在会议纪要中中铁十七局第一公司也没有向联合保险甘肃分公司提出赔偿或给付请求。中铁十七局第一公司也没有提供要求联合保险甘肃分公司先行给付或赔偿的书面申请,联合保险甘肃分公司根据法律规定不负有先行给付的责任,而且联合保险甘肃分公司当时也不知道应当按照原判决金额的50%进行先行赔付。

2.法院观点

一审法院认为,保险合同约定"当发生本保单责任范围内的损失时,被保险人提出申请,本公司(被告)可以预先支付部分赔款,金额限于每次事故损失金额的50%。"根据《中华人民共和国保险法》第二十五条规定:"保险人自收到赔偿或者给付保险金的请求和有关证明、资料之日起六十日内,对其赔偿或者给付保险金数额不能确定的,应当根据已有证明和资料可以确定的数额先予支付;保险人最终确定赔偿或者给付保险金的数额后,应当支付相应的差额。"本案原告于2013年6月20日向被告提交理赔申请后,被告就负有及时核定损失、确定赔偿数额的义务。当保险责任确定而赔偿数额不能确定时,被告就应在2013年8月20日向被保险人先行支付部分赔偿款,这是保险法设计先行赔付制度保护弱势群体、维护社会公平之价值所在。然而被告以赔偿数额不能确定为由,在保险事故发生至今仍迟迟不履行该项义务,有违保险法之诚实信用原则,原告要求被告承担迟延付款损失的诉讼请求,不违反法律规定,本院予以支持。

二审法院认为,中铁十七局第一公司于2013年6月20日向联合保险甘肃分公司提交财产保险出险通知书及洪水事故索赔资料后,联合保险甘肃分公司就负有在法定期限内核定损失、确定赔偿数额的义务。如果给付的保险金数额不能确定,联合保险甘肃分公司就应当根据已有证明和资料可以确定的数额先予支付,并及时委托双方认可的公估机构对涉案事故损失进行理算。联合保险甘肃分公司受理接收中铁十七局第一公司提交的财产保险出险通知书及洪水事故索赔资料后,未能在法定期限内核定损失、确定赔偿数额,也未按照双方合同约定预先支付部分赔款,未委托公估机构对涉案事故损失进行理算,其行为既违反《中华人民共和国保险法》的规定,又违反双方的合同约定,未积极履行赔偿义务,具有明显过错,应当承担过错责任,向中铁十七局第一公司承担迟延付款损失。故一审法院判决联合保险甘肃分公司向中铁十七局第一公司承担迟延付款损失正确,应予以维持。

最高人民法院认为,由于联合保险甘肃分公司不认可中铁十七局第一公司申请理赔的损失项目和范围,故一直未对中铁十七局第一公司的涉案损失进行理赔,从本案的证据可以看出,双方对如何理赔进行过现场勘查以及会议商谈,只是未能达成一致意见。故联合保险甘肃分公司认为中铁十七局第一公司在洪水事故发生后一直未向其提出理赔申请不属实。根据涉案保险合同"当发生本保单责任范围内的损失时,被保险人提出申请,本公司可以预先支付部分赔款,金额限于每次事故损失金额的50%"的约定,联合保险甘肃分公司应在中铁十七局第一公司提出理赔申请后在约定期限内先行支付一半的损失理赔金。由于联合保险甘肃分公司实际并未支付任何理赔费用,实际上扩大了中铁十七局第一公司基于涉案洪水事故发生的损失,故原判决认定联合保险甘肃分公司应支付迟延付款的损失,不存在认定基本事实缺乏证据证明以及适用法律错误的问题。

3.作者观点

(1)我国《保险法》有关保险公司理赔义务之规定

《保险法》第二十二条至第二十五条规定了保险公司的理赔义务,其中第二十二条规定了理赔资料的一次性补充通知义务。 [3]第二十三条规定了法定最长核定期间,即除非合同特别约定,否则即使情形复杂的,保险公司也应当于收到被保险人一方理赔请求后三十日内核定是否属于保险责任;第二十三条还规定了赔偿金额确定后最长十日的保险金给付期间;对于未按照法定或约定时间核定责任或给付保险赔款的,第二十三条要求保险人赔偿被保险人一方因此受到的损失。

《保险法》第二十四条规定了保险公司核定不属于保险责任后法定通知义务,即三日内通知被保险人一方的。《保险法》第二十五条规定了先行赔付义务,即"保险人自收到赔偿或者给付保险金的请求和有关证明、资料之日起六十日内,对其赔偿或者给付保险金的数额不能确定的,应当根据已有证明和资料可以确定的数额先予支付"。

由此可见:一是《保险法》对于是否属于保险责任的核定时间是较为强制的,除非保险合同另有合理约定,否则应在三十日内作出核定;二是《保险法》虽未强制规定理赔金额的确定时间,但规定了六十日的先行赔付时间,尽管保险公司可以以理赔金额未确定作为抗辩,但是从合理预期角度来看,该时间不亦过长。我们理解是因为实践中理赔金额之确定往往较为复杂,不宜作一刀切的强制性规定,但被保险人的合理期待应当被保护。

(2)本案是否存在延期理赔之情形

原被告争议焦点在于"被保险人一方是否提出理赔申请"?被保险人一方(原告)认为提交出险通知和索赔资料时间等同于申请理赔时间,而保险人(被告)则坚持出险通知并非《保险法》第二十五条规定的"理赔申请"。对此,最高法院指出"联合保险甘肃分公司认为2013年6月20日只是出险时间而非中铁十七局一公司申请理赔时间,但并未提交证据证明其主张,故本院不予支持"。可见,法院倾向于认为出险通知与索赔资料之提交时间等同于理赔申请提出时间。我们认为法院之观点更接近情理,被保险人对保险公司内部理赔程序不甚了解,若保险公司认为出险通知不等于理赔申请,则应及早告知,而不应在长期拖延理赔之后再以此作为抗辩理由。

值得关注的是,最高法院认为保险公司未证明申请理赔时间而应承担不利法律后果。从证明责任理论与实践来看,主张适用某法规范之当事人应就该法规范要件之存在承担证明责任,适用《保险法》二十五条之先行赔付规定是原告之主张,本应由原告证明,而从判决书上显示内容来看本案原告并未提交"其已提交理赔申请"之证据,最高法院将此证明责任交由被告保险公司承担貌似不尽合理。然而,我们认为法院是运用自由心证规则认为被保险人一方已经完成了举证责任,其已提交了理赔申请,即出险通知与索赔资料提交可视为理赔申请,而保险公司"未能在法定期限内核定损失、确定赔偿数额,也未按照双方合同约定预先支付部分赔款,未委托公估机构对涉案事故损失进行理算",明显属于未积极履行理赔义务。

从证明原理来看,同一要件事实不能同时由双方当事人承担证明责任,此处,法院所谓保险公司未完成证明应指"反证",即不承担证明责任的一方当事人在承担证明责任的一方当事人已完成证明责任后为避免败诉后果而对对方主张的反驳。罗森贝克指出:"反证是对被法院视为已经得到证实的主张的反驳,如果它使得这一主张重新受到怀疑,就被视为已经提出了反证,对不真实的完全证明不是它的目的。" [4]也就是说反证只需要达到动摇法官心下的程度,无需达到一个完全意义上的证明责任。遗憾的是本案保险公司并未提出任何证据动摇法官心证。

如前所述,《保险法》对于核定损失、确定赔偿数额并无强制性时间限制,本案《保险合同》是否存在有关赔付期限的强制性约定我们不可得知,从判决书上看,合同只规定"可以按照每次事故损失金额的50%"预先赔付,此先行赔付之规定也仅是"可以"之示范性约定,而非"应当"之强制性约定。反观《保险法》之先行赔付也是以"已确定"部分赔付金额为条件,而本案保险公司与被保险人一方就赔偿金额迟迟不能达成一致。即便如此,三审法院均支持了被保险人的延期理赔损失请求。由此可见,对于判断保险公司是否存在延期理赔的问题上,法院的判断是采取"实质大于形式"原则,比《保险法》规定更为严格,不允许保险公司以赔偿金额未定作为拒付或延付保险金之理由。

(3)延期理赔之后果

对于延期理赔之后果,《保险法》规定保险公司"除支付保险金外,应当赔偿被保险人或者受益人因此受到的损失"。根据《保险法》之官方解释,此处之损失通常指直接损失,以利息最为常见。 [5]本案法院也支持了原告有关支付延期利息之请求。

对于利息之计算基准,本案三审法院均以"法院认定之理赔金额"(8168544.88元)为基准,按照保险合同约定之先行给付金额(即50%)计算延期支付利息。

此判断标准初看并不完全符合《保险法》之规定,《保险法》先行赔付是以"已有证明和资料可以确定的数额"为基准的,而本案诉前保险公司认为并不能确定损失金额,并未给予定损。本案三审法院创造性地以"法院认定金额"为准,辅以合同约定确定赔偿基准。我们认为该基准充分体现了司法能动性,值得高度关注,特别是值得保险公司在理赔实务中引以为戒。

【启示】

1.对于保险公司的启示

及时理赔是《保险法》赋予保险公司之法定义务,尽管在具体时限上,《保险法》作出了灵活处理,但是在司法实践中,法院倾向于严格认定保险公司的理赔义务,若长期拒不赔付则可能承担更为严重的法律后果。我们建议保险公司严格依据法律规定和合同约定履行理赔义务,对于案情复杂,理赔金额无法短期达成一致的,也应当尽量对能够认定的损失定损,积极履行理赔义务。

2.对于施工企业的启示

相对于工程建设和施工合同来说,施工企业对于保险合同及保险理赔流程是相对陌生的,同时由于理赔事件往往是小概率事件,因此施工企业往往对保险合同不重视,导致一旦出现理赔事件,囿于对保险合同的认识较为浅显,导致无法及时足额获得保险赔,进而酿成纠纷。我们建议施工企业应对保险合同引起足够的重视,在签订保险合同时应当通过自身对工程造价和工程量清单计价等的造价专业知识协助保险公司完善好保险范围的约定,避免出现诸如便道便桥是否属于保险范围等的争议。在出现理赔事件时,应第一时间按照保险合同的约定履行理赔申请等程序性义务,同时积极就损失进行证据保全,通过照片、视频等证据保存受损现场事实情况。最后施工企业可以就能够确定的损失与保险公司达成一致,剩余的部分再通过包括争议解决机制在内的其他方式予以解决。

Footnote

1 建筑工程一切险是承保各类民用、工业和公共事业建筑工程项目,在建造过程中因自然灾害或意外事故而引起的一切损失的险种。第三者责任险是在本保险期限内,因发生与本保险单所保工程直接相关的意外事故引起工地内及邻近区域的第三者人身伤亡、疾病或财产损失,依法应由被保险人承担的经济赔偿责任。

2 指保险事故发现的时间。

3《保险法》第二十二条:"保险人按照合同的约定,认为有关的证明和资料不完整的,应当及时一次性通知投保人、被保险人或者受益人补充提供。"

4 [德]莱奥·罗森贝克:《证明责任论》,庄敬华译,中国法制出版社2002年版,第201页。

5 吴定富:《<中华人民共和国保险法>释义》,中国财政经济出版社2009年4月第1版。

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