The Taiwan High Court rendered the 104-Bao-Xian-Shang-Yi-2 Civil Decision of March 18, 2015 (hereinafter, the "Decision"), which held that whether a patient "requires hospitalization" must be accompanied by a physician's diagnosis to claim insurance for the hospitalization period. Further, the physician only arranged for hospitalization treatment for reducing the patient's trouble in going back and forth for rehabilitation visits, not because the patient was so sick that hospitalization was required.
Appellee alleged that he entered into the Cigna Life Insurance Stability Term Insurance Contract as well as the Cigna Life Insurance Term Rider on Hospitalized Medical Treatment ("Rider") with Appellant. Due to an occupational injury on February 22, 2012, Appellee's left hand and foot were paralyzed. When Appellee attempted to claim insurance payment for his hospitalization from October 15 through December 31, 2013 ("Period"), he was rejected by Appellant. Appellee thus filed an action to compel payment from Appellant.
The Decision found that Article 9 of the Rider stipulates insurance payments for hospitalization, and under Article 2, Paragraph 7: "The term 'hospitalization' set forth herein shall mean where the insured is required to be hospitalized due to illness or injury based on the physician's diagnosis, and the insured has officially completed the hospitalization formalities and was actually hospitalized to receive treatment." The Decision then reasoned that since the Appellee's physician considered the fact that Appellee could not take care of himself and required assistance from others to undergo rehabilitation, and that transportation was quite inconvenient for Appellee and his family, the physician arranged for Appellee to remain at the hospital for his treatment to reduce the trouble of back-and-forth traveling, not because Appellee's illness was serious enough to require hospitalization. Since Appellee's hospitalization was not necessitated by a physician's diagnosis and thus did not meet the "necessity" criterion, the original lower court's decision was reversed, and the Decision ruled against Appellee.