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  受伤骑手缘何获得“赔了再赔”?

  法官解析,骑手所在公司的投保属“定额给付型”,保险金给付不考虑是否已从其他途径获赔

  阅读提示

  近年来,外卖车辆交通事故纠纷案件时有发生,为了保障外卖骑手权益,一些平台企业采用统一投保方式,为骑手投保商业险。然而,现实中,一些已投保骑手在交通事故中受伤后,仍然遭遇保险赔付困境。

  外卖骑手晚上送餐时不慎滑倒受伤,经司法鉴定,构成十级伤残。该骑手找到保险公司申请伤残赔偿时却遭到拒绝,无奈之下,将保险公司诉至法院。虽然最终获得了保险赔偿,但这起纠纷也引发了骑手的困惑:明明投了商业险,为何保险公司起初却拒付“意外账单”?

  专家表示,为骑手统一投保商业险是维护新就业形态劳动者权益的体现,而后续“怎么赔、赔多少”问题应加强关注。

  “赔了再赔”获法院支持

  来自北京的小彭是某公司从事外卖配送服务的外卖员,平日通过某外卖平台接单,所属公司会在小彭每天上线接单时,为他投保当天的骑手保障组合险。

  一天晚上8点,小彭在送餐过程中不慎滑倒致骨折,在医院接受手术并住院治疗,经司法鉴定,伤情构成十级伤残。随后,他基于劳务关系起诉所属公司,要求赔偿35万元。经北京市西城区人民法院主持调解,该公司向小彭支付18万元。

  据了解,事故发生当日,公司为小彭投保的保险期间为该日上午11时至次日凌晨2时。小彭认为,事故发生在这一期间,自己达到十级伤残,保险公司应赔偿自己意外伤残金6万元。保险公司则认为,小彭已获得18万元赔偿,如果保险公司再赔付,则构成重复赔偿。小彭将保险公司诉至法院。

  最终,法院审理认为,根据保单及条款,该保险属于定额给付型,指在保险事故发生后,保险公司应按照合同约定向被保险人支付保险金,不考虑其是否已从其他途径获得赔偿。小彭虽然已获得18万元赔偿,但并不影响保险公司履行赔付义务。最终,法院判决保险公司向小彭赔偿保险金6万元。

  审理该案的法官刘茜倩提醒,在小彭的案件中,涉及的保险类型为定额给付型,容易与之混淆的保险类型为损失填平型,二者在赔付方式上存在显著区别。“损失填平型保险是指保险公司在保险事故发生后,根据被保险人的实际损失进行赔偿。同时,若被保险人在其他途径获得赔偿,则扣减相应已获偿的数额。因此,是否构成重复获偿,需根据具体的保险条款进行甄别判断。”刘茜倩说。

  “加粗加黑”不等于投保人已阅

  国浩律师(深圳)事务所合伙人陈伟律师告诉记者,司法实践中,保险公司除了以骑手不能重复获赔为由拒绝理赔,还有可能增加免责声明、免责条款等。一旦骑手受伤要求赔偿,保险公司也可能以免责条款作为拒赔或降低赔付的理由。

  近日,上海金融法院就审结了这样一起责任保险合同纠纷案。外卖骑手许先生在送餐途中发生交通事故,造成对方车辆损失9.7万元,他随后向投保的保险公司索赔,却被告知免责条款已经变更,保险公司仅能赔付5万元。许先生不服,向法院提起诉讼。

  2021年,许先生所属公司就通过平台系统为旗下外卖骑手购买了雇主责任险,附加第三者责任险,附加险对于第三者物损并未规定赔偿限额。此后,骑手每日接首单时自动参保,默认复用2021年首次投保时的保险条款,并生成当日保单。

  2023年3月7日,平台与保险公司约定更改第三者物损赔偿责任条款,从原本不单设赔偿限额,变更为按不高于5万元支付赔偿金。同年3月23日,平台正式上线迭代后的保险条款,将变更的条款文字加粗加黑。也是在这一天,许先生在配送途中发生交通事故。

  将免责条款内容加粗加黑是否等于投保人已阅?法院审理认为,更改后的条款限制了最高理赔金额,属于免责条款,保险公司应对其进行明确的提示说明。而平台投保采用大批量自动投保模式,每日默认复用首次保险方案,投保人没有必要也没有义务关注每份保单条款的内容是否发生变化。因此,仅仅把条款文字加粗加黑,无法令投保人清楚知悉变更免责条款的具体内容,没有构成有效提示和明确说明。最终,法院判决保险公司全额支付车辆维修费9.7万元。

  陈伟分析认为,“有效提示和明确说明”,需要保险人在与投保人签订保险合同之前或签订保险合同之时,对于保险合同中所约定的免责条款,除了在保险单上提示投保人注意外,还应当对有关免责条款的概念、内容及其法律后果等,以书面或者口头形式向投保人或其代理人作出解释,以使投保人明确该条款的真实含义和法律后果。

  “新职伤”让骑手多一份保障

  中国政法大学民商经济法学院教授娄宇在接受《工人日报》记者采访时表示,外卖骑手的商业险通常由平台企业代表骑手与保险公司签订协议,为团体意外事故保险。在理赔过程中,可能会导致在保险条款的理解、保险公司提示说明的义务等方面出现分歧,最终不利于骑手权益的保障。作为保险公司,应进一步规范针对外卖骑手的商业险,与管理站点、人力服务公司等联合做好骑手的职业安全培训,其中包含对意外事故保险条款的讲解。

  “保险公司应对免责条款履行法定的提示、说明义务,同时,应当尽可能简化保险审核流程,优化保险条款设置,提升事故理赔效率。”陈伟还提醒平台企业,在为骑手统一投保商业险时,保险的范围、险种外延等应尽可能宽泛,覆盖可能出现的各种风险点。

  2022年7月起,新就业形态就业人员职业伤害保障试点(“新职伤”)在北京、上海、江苏等7省市的外卖、出行、即时配送、同城货运4个行业开展。记者了解到,自试点以来,“新职伤”已覆盖全国7省市超1000万人。

  “未来,应继续完善这一制度,在更多地区、更多行业进行推广,克服商业保险在参保条件、赔付待遇等方面的不确定性。在骑手发生意外事故时,让‘新职伤’切实起到兜底保障作用。”娄宇说。

  记者了解到,目前,部分外卖骑手既有“新职伤”,也投保了商业意外险。日前,广州市中级人民法院公布一起案件——外卖骑手在配送中受伤,保险公司以其已享受职业伤害保障为由拒赔意外伤害险。最终判决认定,职业伤害保障和商业意外险可“双赔”。

  本报记者赵欢《工人日报》(2025年04月17日07版)新闻结尾 塔洛希岛by江冉遗补车,用色彩描绘心情,感受五月天带来的无限激情与感动!的相关文章
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