People's Daily Online 2012118 reported in "Insurance Refusal for Second Surgery":

Because the insurance company refused to pay compensation on the grounds that the "second operation" was not directly related to the traffic accident, Mr. Wang took an insurance company to court and demanded compensation. Recently, Beijing No.2 Intermediate People's Court rejected the insurance company's appeal and upheld the judgment of the court of first instance to pay Mr. Wang 20,000 yuan for medical expenses.

On October 24th, 2065438+0165438/KLOC-0, Mr. Wang took out three insurances for the car involved. On July 5, 20 1 1, a motorcycle driven by Mr. Wang and Mr. Liu was involved in a traffic accident, and Mr. Liu was injured. Mr. Wang takes full responsibility for the accident. Later, Mr. Liu had a second operation because the titanium plate was broken after the open comminuted fracture of the right femoral condyle, and Mr. Wang paid 20 thousand yuan for it.

Mr. Wang sued that he was insured with compulsory insurance and commercial insurance, but the insurance company refused to pay for the second operation and asked the court to order the insurance company to pay for the second operation. The insurance company replied that because the second operation fee was a problem in the treatment process of medical institutions, it was not directly related to traffic accidents and did not agree to pay.

After the court of first instance heard the verdict, the insurance company refused to accept it and appealed to the Second Intermediate People's Court. After trial, the Second Intermediate People's Court held that in this case, Liu's placement of titanium plate was indeed caused by the treatment of injuries caused by traffic accidents, and the insurance company should pay Mr. Wang 20,000 yuan for medical expenses as agreed in the insurance policy. The judgment of the court of first instance is correct and should be upheld.

Extended data:

Explanation:

After the accident, the injured underwent surgery. It's hard to say whether this operation can guarantee the complete cure of the injured. If it is a medical accident or the cause of the injured, then the responsibility should be borne by the hospital or the injured. Only if it is caused by the risk of the operation itself should the insurance company pay the claim.

If the insurance company wants to be exempted from the insurance liability of the second operation, it must prove that the second operation was caused by the injured person himself or by a medical accident in the hospital. You can entrust a professional third-party appraisal institution to issue an appraisal report, or you can apply to the court to designate other appraisal institutions for re-appraisal. If the appraisal opinion excludes the cause of the injured or the medical accident in the hospital, the insurance company shall compensate.

People's Daily Online-Insurance refused to pay for the "second operation". The court decided to pay compensation.