Accident Insurance Liability Confirmation Procedures and Legal Practices Regarding Death Benefits: From Declaration of Death System to Differentiated Compensation for High-Risk Occupations

(IV) Confirmation of Insurance Liability 1. Determining whether the insured has suffered external injury First, it is necessary to determine whether injury has occurred-that is, whether there has been death, disability, or other events requiring treatment, or whether the insured's health or well-being has been impaired, resulting in abnormal behavior, speech, or actions. If injury has been determined, it is necessary to ascertain whether the injured party is the insured person indicated in the insurance contract, and whether the contract is still in effect. If the answer is yes, it is necessary to determine whether the cause of the injury originated from the outside. Here, the "proximate cause principle" should be applied to find the cause of injury. According to the definition of "injury," only when the injury originates from an external harmful object and causes actual harm to the insured's body is it considered an injury; otherwise, it is not covered by accident insurance. 2. Confirming whether the injury suffered by the insured was accidental This requires exploring the insured's subjective behavior based on factors such as the insured's objective actions and the objective environment at the time of the injury, in order to determine whether this injury qualifies as an "accidental injury" and thus becomes an insurable "insurable event." First, determine whether the injury was intentional on the part of the insured. If not, then discuss whether the injury was foreseeable by the insured. If it was unforeseeable, it constitutes accidental injury. If it was foreseeable, then determine whether the insured failed to foresee it due to negligence. If so, it constitutes accidental injury. Conversely, if the injury was indeed foreseeable and anticipated, then discuss the reasons why the insured did not avoid the injury. If it was due to insufficient time to avoid it, it still constitutes accidental injury. If it was due to legal or duty-related prohibitions or due to moral or public-spirited motives leading to the risk of injury, it is still considered accidental injury. Other circumstances are generally not considered accidental injury.

(V) Payment of Death Benefit 1. Elements of Death Insurance Liability Death refers to the cessation of bodily life activities and metabolism. If the insured suffers accidental injury during the insurance period and dies physiologically within the liability period, and the accidental injury during the insurance period is the direct or proximate cause of the insured's death, it clearly constitutes the liability of accidental injury insurance, and the insurer should prepare to pay the insurance benefit. However, if the insured goes missing during the insurance period due to airplane, car, or ship accidents, then two years from the date of the accident, when the court declares the insured dead, the liability period of the accidental injury insurance has already exceeded (generally stipulated to be within one year). In this case, if the insurer insists on not assuming insurance liability based on the liability period, it would obviously harm the interests of the insured beneficiary and defeat the purpose of life insurance in providing economic protection. To address this issue, insurance companies include missing persons clauses in their accidental injury insurance policies or include special provisions regarding missing persons on the policy. These clauses stipulate that if the insured is missing for a certain period (e.g., 3 months, 6 months, etc.) due to an accidental injury, they are considered deceased, and the insurer pays a death benefit. However, if the insured later survives, the recipient of the benefit must return it to the insurer in good faith. 2. Method of Death Benefit Payment: After determining that the insured's death constitutes an accidental injury under the insurance policy, the insurer must fulfill its obligation to pay the death benefit according to the policy's stipulations. Furthermore, some life insurance contracts include supplementary accidental injury insurance clauses that specify the payment of death benefits based on the level of risk within the industry. For example, accidental injury benefits are divided into special benefits and ordinary benefits. Special benefits apply to those engaged in underground, offshore, aviation, and other high-risk work, while ordinary benefits apply to others. The ratio of special benefits to ordinary benefits is 1:2, thus reflecting the principle of equality between rights and obligations in personal insurance contracts.

(VI) Payment of Disability Insurance Benefits 1. Standards for Determining Disability and its Degree The disability referred to in personal accident insurance is basically consistent with the medical definition, including two situations: one is permanent loss (or defect) of human tissue, such as limb amputation; the other is permanent loss of normal function of human organs, such as loss of vision, hearing, smell, speech impairment, or behavioral impairment. If an accidental injury occurs during the insurance period, and the permanent disability caused by the injury can be diagnosed by a designated hospital during this period or within the stipulated liability period, it constitutes the insurance liability of the accidental injury insurance. The insurer shall pay all or part of the insurance benefits according to the degree of disability and in accordance with the prior agreement. If the treatment lasts for a long time, and it is still not possible to determine whether a disability has occurred or what degree of disability has occurred by the end of the liability period, the degree of disability shall be presumed based on the insured's condition at the end of the liability period, and the payment shall be based on this. If the insured does not suffer from tissue or organ defects or functional impairments within 180 days after suffering an accidental injury through treatment or self-repair, it is not considered a disability. To standardize the assessment of disability levels in personal insurance policies by insurance companies and facilitate product development and premium calculation, the People's Bank of China formulated the "Table of Disability Levels and Insurance Benefit Payment Ratios in Personal Insurance" on July 14, 1998. The "Notice on Continuing to Use the Table of Disability Levels and Insurance Benefit Payment Ratios in Personal Insurance" (CIRC Document No. 237) issued by the China Insurance Regulatory Commission also requires that the definition of disability levels and insurance benefit payment ratios in the policy terms and new policy terms submitted by insurance companies continue to be implemented in accordance with the "Table of Disability Levels and Insurance Benefit Payment Ratios in Personal Insurance".