Personal accident insurance insurable risk definition and multi-dimensional classification practice

III. Insurable Risks of Personal Accident Insurance Personal accident insurance covers accidental injuries, but not all accidental injuries are covered by the insurer. Generally speaking, according to the insurer's underwriting capacity, accidental injuries can be divided into three types: generally covered accidental injuries, specially covered accidental injuries, and uncovered accidental injuries. (I) Generally Covered Accidental Injuries Generally covered accidental injuries are those that can be covered under normal circumstances. In summary, generally covered accidental injuries mainly include the following: 1. It must be an injury to the insured's body. Injury specifically refers to the objective fact that the body is harmed and damaged, and has nothing to do with mental or psychological trauma. The underwriting conditions of accident insurance first require that there is a fact of bodily injury, and this injury must occur to the insured. Whether the insured has been injured can be determined by a certificate from a designated hospital or by the inspection of the insurance company's staff; as for whether the "injury fact" is established, it needs to be examined from multiple aspects. 2. It must be an injury caused by external causes or accidents (1) Injuries caused by external causes. External injuries are relative to internal diseases. Some injuries also have a so-called incubation period. For example, a violent collision may cause internal organ or head injury without any excessive discomfort at the time, but in fact, it has caused concussion or displacement of internal organs. At some point in the future, it may suddenly cause post-concussion sequelae or cause internal organ dysfunction. All of these make the boundary between external injuries and internal diseases tend to be blurred. The operating principle of insurance requires that there must be a certain clear boundary. Therefore, special injuries or special diseases must be listed separately in the insurance policy to facilitate the claims process and avoid disputes. (2) Injuries caused by accidents. Injuries caused by accidents refer to injuries that the insured could not foresee or could not foresee beforehand, and therefore could not avoid; or injuries that the insured foresaw but which still occurred against the insured's subjective will. 3. Unintentionally induced personal accident insurance emphasizes that the insured accidental injury is an accidental, sudden event, a physical injury that the insured could not foresee or that occurred against their will. This provision aims to prevent the insured from engaging in moral hazard and exploiting the difficulty in discerning subjective behavior to defraud insurance claims. The nature of an insured intentionally causing harm is entirely different from an insured who foresaw the impending harm but was unable to avoid it due to legal or moral obligations, or who risked danger to save collective property or the lives of others. In the former, the insured subjectively desired the harm to occur, meaning the eventual occurrence did not violate their subjective will, and therefore cannot be considered an accidental injury. In the latter, the insured did not wish to be harmed but acted out of responsibility or morality, which violated their subjective will and constitutes an accident, thus qualifying for coverage. (II) Accidental Injuries Specially Covered Accidental injuries refer to those theoretically insurable risks that insurers generally do not cover due to considerations of liability differentiation, underwriting capacity limitations, or solvency requirements. These risks are only covered through a special agreement between the two parties, sometimes requiring an additional premium. They generally include accidental injuries suffered by the insured during strenuous sports activities, competitive sports, or particularly adventurous activities such as mountaineering, skydiving, skiing, river rafting, racing, boxing, and wrestling. These accidents either have a much higher probability of occurrence than the general level, or the probability varies significantly among different insureds. Therefore, for the sake of operational stability and fairness in the premium burden on the insured, insurance companies generally do not cover them. However, through a special agreement, they can be removed from the exclusions and made insurable risks. It should be noted that there is no absolute boundary between specially covered accidental injuries and generally covered accidental injuries. Some insurance companies may, based on their own technical conditions, underwriting capacity, and the situation in their operating areas, classify certain generally insurable accidental injuries as specially insurable accidental injuries; while some activities that were once classified as specially insurable accidental injuries due to excessive risk have become generally insurable accidental injuries due to the continuous reduction in risk level caused by scientific and technological development. (III) Uninsured Accidental Injuries Uninsured accidental injuries generally refer to those caused by acts that violate legal provisions or social public interests. Insurers generally do not accept such risks. For example: 1. Injuries suffered by the insured in negligent or intentional criminal activities. First, insurance only provides protection for legal acts; only in this way does the insurance contract have legal effect. All criminal acts are illegal, so accidental injuries suffered in criminal activities are not covered by insurance. Second, criminal activities are socially harmful. Providing insurance protection for accidental injuries in criminal activities is tantamount to indirectly supporting these illegal acts, which violates social public interests and is not conducive to social stability. 2. Accidental injuries sustained by the insured during provocation and fighting: Provocation and fighting are intentionally created to instigate conflict. While not necessarily constituting a crime, they pose a social hazard and violate public safety, thus constituting illegal behavior and are therefore not covered. However, it is worth noting that accidental injuries sustained by the insured in self-defense when subjected to unlawful harm by others are due to righteous actions and should be covered. 3. Accidental injuries sustained by the insured while intoxicated, under the influence of drugs, such as falls, drownings, or traffic accidents caused by impaired judgment, excessive excitement, or hallucinations, are considered accidental injuries, but because the cause is immoral behavior, and in most countries, illegal, they are not covered. Generally, insurance companies must explicitly list excluded accidental injuries in the insurance policy as exclusions.

IV. Classification of Personal Accident Insurance (I) Classification by Insured Risk According to the different insured risks, personal accident insurance can be divided into two categories: general accident insurance and specific accident insurance. 1. General Accident Insurance Also known as general accident insurance or personal accident insurance, it refers to insurance that pays insurance money to the insurer when the insured dies or becomes disabled due to ordinary accidental injury during the insurance period. The risk it covers is general accidental injury. It is usually an independent type of insurance, often in the form of short-term insurance, with a term of one year or less, and the content, amount, and method of insurance are determined according to the agreement between the insurer and the insurer. 2. Specific Accident Insurance It is an accident insurance with "three specifics" (specific cause, specific time, specific place) as the binding conditions. The risk it covers is accidental injury caused by a specific cause or accidental injury suffered at a specific time and place. Usually, it requires a special agreement between the policyholder and the insurer, and sometimes the insurer also requires additional premiums. This type of insurance covers accidental injuries including those caused by war, those caused by strenuous sports or dangerous recreational activities, those caused by nuclear radiation, those caused by medical malpractice, and so on. These specially covered accidental injuries can be insured separately, added to other insurance policies, or removed from the exclusions by endorsement or endorsement. (II) Classification by Insurance Liability According to different insurance liabilities, personal accident insurance can be divided into the following four categories. 1. Accidental Death and Disability Insurance This type of insurance only protects the insured from death and disability caused by accidental injury, meeting the insured's insurance needs for accidental injury. Its coverage includes both death and disability caused by accidental injury. The insurance payment due to the insured's death is called the death benefit, and the insurance payment due to the insured's disability is called the disability benefit. This type of insurance is usually added as an add-on clause to other main insurance policies, but it can also be purchased as a standalone insurance policy. 2. Accidental Injury Medical Insurance: This type of personal insurance pays out benefits based on medical expenses incurred by the insured due to accidental injury requiring medical treatment. Its coverage typically stipulates that if the insured suffers an accidental injury during the coverage period and receives hospital treatment at their own expense, the insurer will pay medical insurance benefits according to the contract. Generally, during the contract period, regardless of whether the insured requires hospital treatment due to accidental injury once or multiple times, the insurer will pay benefits as stipulated, but the total medical insurance benefits paid will not exceed the insured amount. 3. Comprehensive Accidental Injury Insurance: This type of insurance combines the previous two types. Its coverage includes both death or disability benefits due to accidental injury and medical insurance benefits for medical expenses incurred by the insured due to the accidental injury requiring hospital treatment. This type of insurance is mostly underwritten separately. 4. Accidental Injury Loss of Work Insurance: This type of personal insurance pays benefits to the insured when they temporarily lose their ability to work due to an accidental injury. Its insurance liability typically stipulates that when the insured suffers death or disability due to an accidental injury to a certain degree, and is unable to perform work that generates income for a certain period, the insurer shall pay the insured or beneficiary a work stoppage insurance benefit according to the contract. This type of insurance aims to protect the insured's income reduction caused by accidental injury and safeguard the interests of those who rely on the insured's income for their livelihood. (III) Classification by Insurance Method According to different insurance methods, personal accident insurance can be divided into two categories: individual accident insurance and group accident insurance. Individual accident insurance is insurance purchased by the policyholder or the insured individually, and one policy only covers one insured; group accident insurance is personal accident insurance purchased by a group, and its insurance liability and payment method are the same as those of individual accident insurance. Since the premium rate of accident insurance is related to the insured's occupation and activities, group accident insurance is often more suitable than individual insurance. Moreover, accident insurance has a short coverage period, low premiums, and high protection. In situations where employers need to bear certain responsibilities for their employees' accidents, group accident insurance is more advantageous to employers. Therefore, compared with life insurance and health insurance, personal accident insurance is the most suitable and appropriate to be purchased in groups. In fact, group accident insurance is the most common type of accident insurance policy. The validity of group accident insurance policies differs from that of individual accident insurance policies: In group insurance, once the insured leaves the group, the policy immediately terminates for that insured, and the group can process a refund for them, while the policy remains valid for other insureds. (IV) Classification by Purpose of Insurance According to different purposes of insurance, personal accident insurance can be divided into two categories: voluntary accident insurance and mandatory accident insurance. Voluntary accident insurance refers to various accident insurance policies that the policyholder purchases voluntarily. Mandatory accident insurance, on the other hand, is insurance that the state mandates the parties to participate in through various laws and regulations. It is based on the validity of national insurance laws and regulations, which establishes a relationship of rights and obligations between the two parties. For example, my country once implemented mandatory travel accident insurance. In addition, according to the insurance period, personal accident insurance can also be divided into one-year accident insurance, very short-term accident insurance, and long-term accident insurance.