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  • Interpretation
  • No.316
  • Date
  • 1993/05/07
  • Issue
    • Does the interpretative letter issued by the Ministry of Civil Service conflict with the Constitution, which indicates that the insured who became disabled by accident during the covered period and now is comatose is not entitled to claim disability benefits if his physical condition requires continuous medical care?
  • Holding
    •        The illness, injury and disability as referred to in Article 3 of the Public Functionaries Insurance Act belong to a different subcategory of insurance peril. In the case where the insured becomes disabled by accident during the covered period, the insured shall be entitled to disability benefits in accordance with Article 14 of the same Act. It is another matter regarding the conditions under which the insurer shall bear medical costs for the insured. If there is no error in the permission to terminate medical treatment for pathological changes of the cerebrum of a comatose person as mentioned in a letter dated October 6, 1990, from the Ministry of Civil Service, Ref. No. 79-Tai-Hwa-Teh-Yi-0470777, then such case qualifies for disability benefits. However, citing a resulting complication which requires further treatment as reason for denying disability benefits confuses disability benefits with medical indemnity for illness and injury, and adds more terms and conditions than prescribed by the laws. The aforesaid contradicts the intention of the Constitution with regard to implementing social insurance to take care of the disabled and to guarantee the rights of the citizens and, therefore, the said letter shall no longer apply. Medical treatment for pathological changes of the cerebrum of a comatose person may be terminated, but special care for the said individual weighs more heavily than disability benefits. The current lack of regulations, in insurance for government employees, regarding professional medical care shall be promptly examined and rectified. Furthermore, after obtainment of disability benefits, if a comatose person with pathological changes of the cerebrum needs medical treatment for injury or illness other than pathological changes of the cerebrum, the medical costs incurred shall, justifiably, still be borne by the insurer because such medical condition is under a different covered subcategory.
  • Reasoning
    •        Insurance for public functionaries is one type of social insurance. As stated in Article 155 of the Constitution, "The State, in order to promote social welfare, shall establish a social insurance system. To the aged and the infirm who are unable to earn a living, the State shall give appropriate assistance and relief." The approval of claims for disability benefits involves the guaranty of constitutional rights of the citizen. In Article 3 of the Public Functionaries Insurance Act, there are seven subcategories of insurance perils: childbirth, illness, injury, disability, annuity, death, and funeral arrangements for family members; among them, illness, injury, and disability, respectively, belong to a different subcategory. According to Article 58, Paragraph 1, in the Enforcement Rules of the said Act, if the insured is disabled due to an insurance peril and there is no possibility for rehabilitation after termination of medical treatment, and thus (diagnostically) he/she is confirmed as permanently disabled, then the insured shall be paid with cash indemnity in accordance with disability criteria as prescribed in Article 14 of the same Act. The aforesaid has no connection with Article 3, Paragraph 5, Subparagraph 4, of the same Act, which stipulates that after payment of disability benefits for a disability caused by injury or illness, the insured shall not claim medical indemnity for the same injury or illness; that is, the insurer shall not be responsible for the insured regarding medical costs incurred for the same injury or illness. However, the aforesaid is indemnity under a different subcategory of covered injury or illness, and has no connection with statutory disability benefits for the insurance peril that already happened. Furthermore, the content of "same injury or illness" as referred to in the aforesaid Act is itemized in Article 51, Paragraph 2, in the Enforcement Rules for the same Act as: (1) the part suffering injury or illness is the same as the original disabled part; (2) the medical term of the injury or illness is the same as that of the original injury or illness which caused the disability; and (3) severity of the injury or illness has not yet exceeded the covered scope regarding the original disability. The aforesaid does not put infections and complications not relating to the same injury or illness in the covered scope for the "same injury or illness." Besides, if the various infections and complications can also affect able-bodied people, then there is no justification for expanding interpretation for such as the "same injury or illness." If there is no error in the permission to terminate medical treatment for pathological changes of the cerebrum of a comatose person as mentioned in a letter dated October 6, 1990, from the Ministry of Civil Service No. 79-Hwa-Teh-Yi-0470777, then such case qualifies for disability benefits. However, citing a resulting complication which requires further treatment as a reason for denying disability benefits confuses disability benefits with medical indemnity for illness and injury, and adds more terms and conditions than prescribed by the laws. The aforesaid contradicts the intention of the Constitution with regard to social insurance concerning taking care of the disabled and guaranteeing rights of the citizen and, therefore, the said letter shall no longer apply. Medical treatment for pathological changes of the cerebrum of a comatose person may be terminated, but special care for said individual weighs more heavily than disability benefits. The current lack of regulations, in insurance for government employees, regarding professional medical care shall be promptly examined and rectified. Furthermore, after obtainment of disability benefits, if a comatose person with pathological changes of the cerebrum needs medical treatment for injury or illness other than pathological changes of the cerebrum, the medical costs incurred shall, justifiably, still be borne by the insurer because such medical condition belongs to a different subcategory of injury and illness.  
      
    • *Translated by Dr. C.Y. Huang of Tsar & Tsai Law Firm.
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