A boiler worker at a paper mill died suddenly while working. After compensating his family, the factory refused to claim compensation from the insurance company and sued the insurance company to the court. Recently, the Chaoyang District People's Court in Beijing held a public hearing on this case and determined that the worker's death at work met the conditions of "deemed work-related injury" in the insurance terms, and was within the scope of insurance claims. The court ruled in accordance with the law that a certain insurance company should compensate a paper mill with an insurance premium of 500000 yuan. The case shows that on a certain evening in November 2023, Mr. Zou, a boiler worker at a paper mill, suddenly fainted and fell into a coma while working. The factory owner, Mr. Yu, and others discovered the situation and immediately called the emergency and police numbers. Mr. Zou passed away due to sudden death, despite the efforts of emergency doctors on site. After mediation, a paper mill signed a people's mediation agreement with Mr. Zou's family, agreeing that the paper mill would compensate 540100 yuan. A certain paper mill once insured Mr. Zou with employer's liability insurance, with a death compensation of 500000 yuan. After the paper mill paid compensation to Mr. Zou's family as agreed, they applied for insurance claims from a certain insurance company based on the employer's liability insurance they had purchased, but were refused. Therefore, they filed a lawsuit with the court demanding that the insurance company compensate 500000 yuan and interest. The agent of a certain insurance company defended in court that "work-related injury or deemed work-related injury situation" falls within the scope of the employer's liability insurance claims involved in the case, but the insurance contract clearly stipulates that the determination of "work-related injury or deemed work-related injury situation" should be based on the work-related injury determination decision issued by the social insurance administrative department, and the insured should submit a work-related injury determination letter when applying for compensation. The aforementioned provisions regarding the requirement for work-related injury identification belong to insurance liability clauses rather than exemption clauses. A certain paper mill refuses to conduct work-related injury identification, and the insurance refusal liability resulting from this should be borne by itself. The Chaoyang Court, after trial, believes that the insurance clauses involved in the case have clearly defined that the situation of work-related injury or deemed work-related injury shall be determined in accordance with the provisions of the Work Injury Insurance Regulations and local implementation measures. The Work Injury Insurance Regulations have clear provisions on which situations to determine work-related injury and which situations to determine deemed work-related injury. In this case, it can be judged whether the accident involved in the case falls within the scope of insurance liability based on the materials submitted by a certain paper mill. The court believes that the provisions regarding the determination of work-related injuries in this case should be classified as exemption clauses in nature. If an insurance company fails to provide evidence to demonstrate the above disclaimer clause, it should not be effective for a paper mill. The court held that although a certain paper mill did not apply for work-related injury recognition, the content recorded in the "Situation Explanation" issued by the local police station indicates that Mr. Zou's death occurred during working hours and at work position, and his death was sudden and urgent, meeting the conditions of sudden illness death or death within 48 hours after ineffective rescue. Therefore, Mr. Zou's death meets the criteria for recognition as work-related injury and falls within the scope of insurance claims involved in the case. On the day of the verdict, the court sent a judicial suggestion to a paper mill on "protecting the rights and interests of workers in accordance with the law" and a judicial suggestion to an insurance company on "defining insurance exemption clauses and reminding the fulfillment of obligations". At present, the first instance judgment has not yet come into effect. (New Society)
Edit：Lubaikang Responsible editor：Chenze
Source：GMW.cn
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