《保险研究》20260108-《健康保险承保范围解释论之形塑》（樊启荣、丁芳园）

［摘   要］健康保险承保合同成立后的“新生疾病”，合同设计上通过疾病定义条款、既往症条款以及等待期条款予以具体界定，三者之间的逻辑关联及规范功能宜进行整体性解释。疾病定义条款旨在筛选所欲承保的疾病类别，不宜添加“被诊断”或“具体治疗方式”的限定语，宜直接适用对“疾病”症状及特征的客观描述。既往症条款旨在实现对“旧病”的精确裁剪，以主观标准为主、兼顾客观标准判定既往病症的发病时点，将被保险人对疾病不知情的纳入承保范围，将被保险人对疾病知情而未如实告知的，允许保险人就该项疾病主张免责。等待期条款旨在解决潜伏性疾病所导致的是“新病”还是“旧病”的判断难题，维护对价平衡，以达为风险共同体稳定提供损失填补的目的。三大条款共同构成健康保险合同核心给付条款，均不应判定为免责条款。

［关键词］健康保险；承保范围；疾病定义条款；既往症条款；等待期条款

［基金项目］本文是国家社会科学基金一般项目“社会治理创新背景下责任保险法的理论变革与制度创新研究”（15BFX167）的阶段性成果。

［作者简介］樊启荣，中南财经政法大学法学院教授、博士生导师，研究方向：保险法；丁芳园，中南财经政法大学法学院博士研究生，研究方向：保险法。

Shaping Health Insurance Scope of Coverage with Interpretive Theory

FAN Qi-rong，DING Fang-yuan

Abstract：Health insurance covers new illnesses arising after the insurance contract is established.In contract design，post-insured illnesses are specifically defined through the disease definition clause，pre-existing condition clause，and pre-existing exclusion period clause.Therefore，the logical relationship and regulatory function among these three clauses should be interpreted holistically.The disease definition clause aims to screen the categories of illnesses to be covered.It is not advisable to add qualifying terms such as ‘diagnosed’ or ‘specific treatment methods’;instead，it should directly apply objective descriptions of the symptoms and characteristics of the disease.The pre-existing condition clause seeks to precisely delineate ‘pre-existing illness’.It primarily relies on subjective criteria，supplemented by objective standards，to determine the onset date of pre-existing conditions.This clause includes illnesses unknown to the insured within the scope of coverage.Conversely，for illnesses known to the insured but not truthfully disclosed，the insurer is permitted to claim exemption from liability for that specific illness.The pre-existing exclusion period clause addresses the challenge of determining whether latent conditions constitute ‘post-insured illness’ or ‘pre-insured illness’，safeguarding the balance of consideration to ensure stable loss compensation for the risk pool.Collectively，these three clauses form the core benefit provisions of health insurance contracts and should not be classified as exclusion clauses.

Key words：health insurance;scope of coverage;disease definition clause;pre-existing condition clause;pre-existing exclusion period clause