Accidental Injury Insurance Liability Determination and Causal Logic: From the Proximate Cause Principle to the Identification of Disease Triggers

Section 2 Insurance Liabilities of Personal Accident Insurance I. Content and Characteristics of Insurance Liabilities (I) Content of Insurance Liabilities Personal accident insurance covers death benefits, disability benefits, and medical expense benefits, but in practice, only one or a few of these may be covered. Theoretically, personal accident insurance can also include compensation for lost wages. However, in current insurance practice in my country, there are very few provisions regarding compensation for lost wages under personal accident insurance; only a very few types of insurance stipulate compensation for lost wages. (II) Characteristics of Insurance Liabilities Personal accident insurance covers disability or death caused by accidental injury, but not disability or death caused by illness. Life insurance death insurance covers death caused by illness or accidental injury, but not disability caused by accidental injury. Endowment life insurance covers death caused by illness or accidental injury, and the insured's survival until the end of the insurance period.

II. Determination of Insurance Liability: The insured suffers an accidental injury during the insurance period; the insured dies or becomes disabled or pays medical expenses during the liability period; and the accidental injury is the direct or proximate cause of the death, disability, or medical expenses. Personal accident insurance liability must be constituted by these three necessary conditions, none of which can be omitted. (I) Accidental Injury Suffered by the Insured: Accidental injury emphasizes two aspects. A mere subjective accident without the objective fact of injury, a close call, does not constitute accidental injury. Conversely, if the objective fact of injury occurs without subjective accidental support, it can only be "inevitable injury" or "intentional injury," which still differs from the term "accidental injury." In general, the accidental injury suffered by the insured must be an objective fact, not a figment of imagination or speculation; the objective fact of the accidental injury suffered by the insured must occur within the insurance period. (II) Death, Disability, or Medical Expenses Paid by the Insured: The death, disability, or medical expenses paid by the insured during the liability period is the second necessary condition for constituting the insurance liability of accident insurance. 1. Death or Disability of the Insured: Generally, death refers to physiological death in a medical sense, that is, the cessation of bodily life activities and metabolism. Insurance contracts have legal effect and are bound by the General Principles of Civil Law. Therefore, in insurance law, especially in types of insurance such as accident insurance, the legal meaning of "death" applies. There are two types of legally effective death: one is biological death, which is the permanent cessation of heartbeat and respiration, at which point the body enters a state of death. In recent years, the new concept of "brain death" has been proposed. Brain death refers to the complete cessation of all brain functions, including the cerebrum, cerebellum, and brainstem; that is, the brain dies first, followed by the cessation of respiration and heartbeat. The other is declared death, which is a legally established system of presumed death according to legal procedures. If a citizen has been missing for four years, or has been missing due to an accident for two years from the date of the accident, or has been missing due to an accident and relevant authorities have certified that the citizen is unlikely to be alive, the People's Court may, upon application by an interested party, legally presume death, that is, declare the citizen dead. Disability under personal accident insurance refers to bodily injury directly caused by an accidental injury, resulting in the loss or dysfunction of tissues or organs. In accident insurance, if the insured suffers an accidental injury but, through treatment or self-repair, does not experience any remaining tissue or organ loss or dysfunction within 180 days, it is not considered a disability. 2. Death, disability, or medical expenses resulting from accidental injury within the insurance period must occur within the liability period. The insurance period is the date on which the insurance coverage begins and ends, as clearly stipulated in the insurance contract. If the insured suffered an accidental injury or other adverse effects on their health before the start of the insurance period, but dies, becomes disabled, or incurs medical expenses within the insurance period, this does not constitute insurance liability for the accident insurer. For insured individuals who suffer injury within the insurance period but die, become disabled, or incur medical expenses after the insurance period ends, insurance companies generally stipulate a liability period in the contract. The liability period is a concept unique to accident and health insurance, referring to a timeframe (e.g., 90 days, 180 days, 1 year) from the date of the insurable accidental injury. If death or disability occurs during this period, the accident insurer remains liable. If the insured suffers accidental injury within the insurance period and dies within the liability period, it clearly constitutes insurance liability, and death benefits should be paid. For disabilities caused by accidental injury, the liability period essentially determines the degree of disability. After an accidental injury, the insured often needs a period of treatment to determine whether and to what extent disability has occurred. If the final result cannot be determined by the end of the liability period, then it should be presumed that the insured's tissue loss or loss of normal organ function at that point in time is permanent. The degree of disability is determined based on the situation at that point, and disability benefits are paid accordingly. After this, even if the insured recovers or the degree of disability is reduced through treatment, the insurer cannot recover the overpaid insurance money; conversely, even if the insured's degree of disability worsens or even dies later, the insurer cannot demand additional insurance money. The same principle applies to medical expenses, as the medical process often lasts for a period of time, and corresponding expenses will continue to accrue. However, in either case, if the accumulated insurance amount reaches the maximum limit, the insurance liability will automatically terminate. (III) Accidental injury must be the direct or proximate cause of death, disability, or medical expenses. 1. Accidental injury is the direct cause, meaning the accidental injury directly causes the insured's death, disability, or additional medical expenses. For example, if the insured slips and falls on a snowy day, resulting in a fracture, requiring hospitalization and increasing expenses such as hospitalization fees and surgical fees; or if the insured's plane crashes due to sudden weather changes, causing the insured's accidental death. When an accidental injury directly leads to death, disability, or treatment, the insurer should pay death benefits, disability benefits, or medical insurance benefits as stipulated. 2. Accidental Injury as Proximate Cause: Although an accidental injury is not the direct cause of death, disability, or medical treatment, it is the initial cause of a series of related events. The proximate cause principle is a fundamental principle in insurance used to determine the causal relationship between a dangerous accident and the injury to the insured object, thereby determining the insurer's liability for compensation or payment. Generally, the proximate cause principle does not apply to personal insurance, except for personal accident insurance. A proximate cause refers to the direct, most effective, and decisive factor that causes the loss to the insured object. For example, if an insured dies from rabies after being bitten by a rabid animal, the rabies bite is an accidental injury, but it did not directly cause the insured's death. The direct cause of the insured's death is the disease (rabies is a disease). Since the rabies bite is the initial cause of the insured contracting rabies, and no other independent factors intervened, the accidental injury is the proximate cause of the insured's death, and the accident insurer is obligated to pay the death benefit. 3. Accidental Injury as a Triggering Factor: An accidental injury triggers or worsens the insured's pre-existing condition, resulting in death, disability, or the need for medical treatment. For example, an insured with a pre-existing blood disease might bleed to death from a minor injury. Or, an insured with heart disease might die from a heart attack triggered by a bumpy ride. In these cases, the injury or bumpy ride can be considered an accidental injury, but the harm it would cause to a healthy person is negligible. The actual cause of death is the pre-existing condition; the accidental injury is merely a trigger. In such cases, the accident insurance insurer generally does not pay the insurance benefit based on the sum insured and the insured's final outcome, but rather on the potential consequences of such an accidental injury for a healthy person.