醫療診斷在醫療保險中的評價標準與保險契約的疑義解釋
Standards for Evaluating Medical Diagnoses in Medical Insurance and the Interpretation of Ambiguities in Insurance Contracts
在醫療保險給付關係中，醫療處置的必要性，應以診斷醫師見解為準，或者是須以相同專業醫師的客觀標準為準，影響被保險人權益甚鉅。本文認為應以診治醫師的判斷為準，始符合法律上關於契約疑義解釋的規定。最大誠信原則僅能作為個案中糾正保險濫用的例外手段，不足以合理化客觀說。欲根本地解決被保險人面臨支出醫療費用卻無法獲得保險給付的兩難問題，須將商業醫療保險的給付方式改採類似全民健保的給付與結算方式，方能達成。
In the context of medical insurance benefit relationships, whether the necessity of medical treatment should be determined according to the judgment of the treating physician or by an objective standard based on the views of physicians with comparable professional expertise has significant implications for the rights and interests of the insured. This article argues that the judgment of the treating physician should prevail, as this approach is more consistent with the legal rules governing the interpretation of contractual ambiguities. The principle of utmost good faith should serve only as an exceptional means of correcting abusive practices in individual cases and is insufficient to justify the adoption of an objective standard. To fundamentally resolve the dilemma faced by insured persons who incur medical expenses but are nevertheless unable to obtain insurance benefits, the benefit structure of commercial medical insurance must be reformed to adopt a payment and settlement mechanism similar to that of the National Health Insurance system. Only through such a systemic reform can this dilemma be effectively addressed.
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