論保前疾病與違反告知義務之認定
On the Controversies Surrounding the Determination of Pre-existing Conditions and the Breach of the Duty of Disclosure
實務上保險人常以違反告知義務與投保前已在疾病中為理由拒賠，但兩者之認定與區別，仍應審慎判斷。本文以為，告知義務可能包含對過去病史之問題，但理論上與保前疾病不保屬不同之面向。在認定保前疾病時，對於疾病已有外表可見之徵象，在客觀上被保險人不能諉為不知之標準，應審慎認定，對於不具特異性之症狀尤是。如果保險人或是保險業務員知悉被保險人已經有保前疾病，而仍繼續維持契約者，可參酌民法誠信原則，英美法棄權或禁反言之法理，使保險人仍必須負責。對於業務員之告知，原則上應可對保險人發生效力。
In practice, insurers frequently deny claims by alleging a breach of the duty of disclosure or the existence of a pre-existing condition. However, the legal determination and differentiation of these two grounds warrant rigorous scrutiny. This paper posits that while the duty of disclosure may encompass inquiries regarding a policyholder’s past medical history, it remains theoretically distinct from the coverage exclusions applicable to pre-existing conditions. When establishing the existence of a pre-existing condition, the judicial criterion requiring the disease to exhibit “externally visible manifestations of which the insured cannot objectively claim ignorance” must be applied with the utmost caution, particularly concerning non-specific symptoms. Furthermore, should an insurer or its agent acquire knowledge of a pre-existing condition yet elect to maintain the insurance contract, the insurer must remain liable. Such continuous liability can be substantiated by the principle of good faith under civil law, drawing upon the common law doctrines of waiver and estoppel. In principle, any disclosure made to an insurance agent shall be legally imputed to the insurer.
007-016
