Insurance Dispute Over CNY 36,462 in Traffic Accident
A traffic accident in Eastern China City led to a dispute between an injured pedestrian and an insurance company over coverage of medical expenses, future treatment costs, and appraisal fees. The case reached an appellate court after the insurer argued that part of the claim was not covered and that a contractual arbitration clause should apply.
The accident occurred on February 28, 2011, when a vehicle owned by the Shibali Town Health Center and driven by Mr. Fu struck Ms. Sun, a farmer born in 1962. Ms. Sun suffered facial lacerations and other injuries, requiring 49 days of hospitalization and medical costs of CNY 20,614.90. The traffic police found Mr. Fu fully at fault. The vehicle was insured with PICC, including compulsory liability insurance (CNY 122,000 limit) and commercial third-party insurance (CNY 200,000 limit). The health center had advanced CNY 1,500 for Ms. Sun’s treatment. Ms. Sun, a rural resident, sought compensation for medical expenses, lost wages, nursing care, and future facial surgery estimated at CNY 7,000 by a forensic appraisal, plus CNY 1,000 for the appraisal itself.
At the original hearing, Ms. Sun presented hospital records, a police accident report, and a forensic appraisal from Anhui Fair Judicial Appraisal Institute. The appraisal stated that facial plastic surgery and cosmetic treatment would cost approximately CNY 7,000. The trial court also considered testimony from the parties and the insurance policy terms. The insurance company did not provide evidence of its arbitration clause claim at that stage. The original court calculated total damages at CNY 36,462.36, including medical fees, lost income (CNY 1,890.91 at CNY 38.59 per day for 49 days), nursing care (CNY 3,329.55 at CNY 67.95 per day), hospitalization meals (CNY 980 at CNY 20 per day), transportation (CNY 147 at CNY 3 per day), appraisal fee of CNY 1,000, and future treatment of CNY 7,000. The court ordered PICC to pay this amount within seven days, deducting the health center’s advance.
On appeal, PICC raised two main arguments. First, the commercial insurance contract contained an arbitration clause, so the trial court should not have handled the commercial insurance claim in the same lawsuit. Second, the CNY 7,000 future treatment cost and CNY 1,000 appraisal fee were indirect losses not covered by the policy; specifically, the future treatment was for cosmetic purposes and lacked a medical institution’s certificate. The appellate court found that PICC failed to provide any documentary evidence supporting the alleged arbitration clause. Under the relevant law, a party who asserts a contractual clause bears the burden of proof. Because PICC did not meet this burden, the court rejected that argument.
The appellate court then turned to the disputed expenses. It noted that the forensic appraisal clearly determined that Ms. Sun’s facial injuries required plastic surgery as follow-up care. The court held that such future medical costs, though not yet incurred, could be compensated together with the already paid medical expenses because the need was established by expert evidence. Regarding the appraisal fee, the court considered it a direct loss resulting from the accident, necessary to establish the extent of injury and treatment costs. Therefore, the trial court’s decision to include both amounts in the damages award was proper.
The court affirmed most of the original judgment but issued a minor modification. It clarified that PICC must pay CNY 36,462.36 within seven days, and Ms. Sun must then return the CNY 1,500 advance to the health center from that payment. The health center was no longer liable for any additional compensation. The appellate court also ordered PICC to bear the CNY 300 appeal fee. This final judgment upheld the principle that insured parties may recover proven future medical expenses and appraisal fees when supported by expert evidence, and that arbitration clauses must be properly proven to exclude court jurisdiction.
Disclaimer: This article is for informational purposes only and does not constitute legal advice.