Recently, a personal insurance contract dispute case we represented was tried by the People's Court of Chaoyang District, Beijing, and the Beijing Financial Court. The case was finally settled through mediation. Although the case is concluded, the legal issues involved in the case are still worth considering.

In this case, the insurance company believes that the provisions of Article 25 of the Interpretation of the Supreme People's Court on Several Issues Concerning the Application of the Insurance Law of the People's Republic of China (III) (hereinafter referred to as the "Judicial Interpretation of the Insurance Law (III)") should be applied, but the courts at both levels have not responded to this. So, in judicial practice, how does the court apply Article 25 of the Judicial Interpretation of the Insurance Law?
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1、 Legal provisions

Article 25 of the Judicial Interpretation of the Insurance Law stipulates that if it is difficult to determine whether the insured's loss is caused by an insured accident or a non insured accident or an exemption, and the party concerned requests the insurer to pay the insurance benefits, the people's court may support it in accordance with the corresponding proportion.

2、 Applicable conditions

According to the above provisions, in a case of dispute over a personal insurance contract, if the cause of the insured's loss is difficult to determine when the parties request the insurance company to pay the insurance benefits, the court may exercise its discretion in accordance with the law and order the insurance company to compensate the parties according to a certain proportion of the insurance benefits. Obviously, the prerequisite for the application of this article is that "it is difficult to determine the cause of the insured's loss.".

In litigation cases, it is the legal duty of judges to ascertain the facts. In cases of disputes over personal insurance contracts, the referee should follow the principles of fairness and justice, ascertain the facts to the maximum extent, and determine the "cause of the insured's losses" on this basis. "Only after exhausted various means and still unable to identify the cause of the accident can the referee make a decision in accordance with this article.". "If the court finds out the cause of the accident or establishes a" high probability "belief in the cause of the accident through court investigation, as well as evidence adduced by the parties, then this provision has no room for application.".

3、 Observation and Interpretation of the Application of Law

In order to observe the judicial application of Article 25 of the Judicial Interpretation of the Insurance Law (III), we have searched a large number of effective judgments through "Wicko First". After searching, it is found that this article has a relatively high frequency of application in cases of disputes over accidental injury personal insurance contracts. We have found that in cases where the plaintiff has provided corresponding evidence of accidental injury, insurance companies generally claim that the evidence provided by the plaintiff fails to prove the fact of accidental injury, and then request payment of insurance benefits in a certain proportion; In cases where the plaintiff fails to provide corresponding evidence of accidental injury, the plaintiff generally requires the court to judge the insurance company to pay insurance benefits in a certain proportion.

In the above-mentioned cases, regardless of who claims to pay the insurance benefits in accordance with the corresponding proportion, the court usually requires the insurance benefit claimant to "provide all the evidence and information it can provide related to confirming the nature, cause, degree of loss, etc. of the insurance accident." In other words, in the case of personal insurance contract disputes involving accidental injury, the plaintiff has the burden of proving the fact of "accidental injury.".
If the plaintiff fails to fulfill the burden of proof, it indicates that the evidence provided by the plaintiff fails to form a high degree of confidence for the judge. Therefore, the fact that the plaintiff claims "accidental injury" will be difficult to obtain court support, and the court will consider that the cause of the insured accident is "other reasons than accidental injury.". At this time, the cause of the insurance accident is determined, and there is no applicable situation as stipulated in Article 25 of the Judicial Interpretation of the Insurance Law (III).

"If the plaintiff has completed the burden of proof of accidental injury, or the evidence provided by the plaintiff has established the judge's inner conviction of the existence of the fact, then, according to the allocation rules of burden of proof," the parties who claim that the legal relationship has been changed, extinguished, or their rights have been infringed shall bear the burden of proof for the basic fact that the legal relationship has been changed, extinguished, or their rights have been infringed. "At this time,", Insurance companies need to provide evidence to prove that the right of claim for insurance benefits has been hindered by certain facts. For example, the insured person has a previous medical history.

According to the evidence provided by the insurance company, if the judge fails to form a high degree of confidence that "there is a certain causal relationship between the past medical history and the insurance accident," then the judge will rely on the facts of the accidental injury claimed by the plaintiff. At this point, the fact of accidental injury claimed by the plaintiff is established, and there is no situation where "the cause of the insured's loss is difficult to determine", and there is naturally no room for the application of Article 25 of the judicial interpretation of the insurance law.

On the contrary, if the judge has formed a high degree of certainty that "there is a certain causal relationship between the past medical history and the insured accident," then a situation arises: the loss of the insured cannot be ruled out as the cause of accidental injury, nor can it be ruled out as the cause of the insured's own disease. The ultimate cause of the accident cannot be determined. At this time, the judge usually determines the proportion of insurance benefits paid by the insurance company based on comprehensive factors such as the cause of the accident, the ability of both parties to provide evidence, and so on. In the cases we searched, some courts ruled that insurance companies should pay 70% of the compensation, while others ruled that insurance companies should pay 50% of the compensation.

4、 Summary

Through the above analysis, we can see that the application of Article 25 of the Judicial Interpretation of Insurance Law (III) is often closely related to the allocation of the burden of proof. In personal insurance contract disputes, the insured/beneficiary needs to bear the burden of proof for the cause of the insured accident, and the insurer needs to bear the burden of proof for the existence of the exemption. The court can only determine whether there is a situation where "the cause of the insured's loss is difficult to determine" after the parties have completed the burden of proof, and then determine whether to apply the provisions of Article 25 to make a decision.