《保险研究》20221109-《意外伤害保险中被保险人死因不明时保险责任的认定》（武亦文、刘洁琼）

［摘   要］由于意外伤害保险被保险人死因不明时保险责任认定立法上规定的粗疏与理论探讨上的阙如，司法实务中裁判规则不一，法院存在基本概念的混淆、法律适用错误以及裁量标准不统一等问题，以致同案不同判的现象频发。被保险人死因不明分为“事实因果关系不明”和“法律因果关系不明”。在法律因果关系不明时，通过意外伤害保险责任认定的实体法规则确定责任归属，法院先进行事实上因果关系判定找出“条件”，再根据比例因果关系原则确定各个条件作用力对应的比例，最后根据意外伤害的“外来性、突发性、非本意性”三个构成要件判断哪些条件符合意外性特征，根据《保险法司法解释(三)》第25条确定保险金的给付比例。在事实因果关系不明时，法院需要判断索赔方是否履行及时通知义务以及资料提交的初步证明义务，保险人是否履行提示举证义务，违反相应的义务即视为对死因不明具有过错。如果索赔方没有过错而保险人具有过错，则保险人应当承担全部的保险金的给付责任；如果索赔方有过错而保险人不具有过错，则保险人不承担保险金的给付责任；如果双方均具有过错，则应当按照过错的程度按照比例分担保险责任。

［关键词］死因不明；意外伤害；保险法上的因果关系；比例因果关系原则；举证责任

［基金项目］本文系2020年国家社科基金后期资助项目“保险法上道德风险控制机制研究”(20FFXB030)的阶段性研究成果。

［作者简介］武亦文，武汉大学法学院教授，研究方向：保险法、卫生健康法；刘洁琼，武汉大学大健康法制研究中心研究助理，研究方向：保险法、卫生健康法。

Determination of Insurance Liability when Cause of Death of the Insuredis Unknown in Accident Insurance

WU Yi-wen,LIU Jie-qiong

Abstract：Due to the lack of the legislative provisions and theoretical discussion on the determination of insurance liability when the cause of death of the insured of accident insurance is unknown,there is no unified judgment rule in the judicial practice,and there are problems such as confusion of basic concepts,wrong application of laws and inconsistent judgment standards in the judicial practice,resulting in frequent occurrence of different judgments in the same case.The unexplained cause of death of the insured is divided into "unexplained causation in factual" and "unexplained causation in legal".When the causation is unknown in legal,the insurance liability can be determined by the substantive law rules:the court first determines causation in factual to find out the "conditions",then determines the corresponding proportion of each condition force according to the principle of proportional causation,and finally determines which conditions meet the factors of accident (i.e.external,sudden and involuntary).The insurer should then determine the proportion of insurance benefits to be paid according to Article 25 of the 3rd Judicial Interpretation of the Insurance Law.When the causation is unknown in factual,the court needs to judge whether the claimant has fulfilled the obligation of notification and the preliminary burden of proof and whether the insurer has fulfilled the obligation of reminder for presenting evidences.If either party violates the corresponding obligation,it shall be deemed to be at fault for the unknown cause of death.If the claimant is not at fault but the insurer is at fault,the insurer shall bear the insurance liability in full;if the claimant is at fault and the insurer is not at fault,the insurer shall not bear the insurance liability;and if both parties are at fault,the insurance liability shall be shared in proportion to the extent of the fault.

Key words：unknown cause of death;accidental injury;causation in insurance law ;the proportional causation principle ;burden of proof