[Direct answer]In the Beijing area, if an insurance claim is rejected, the first step is to request the insurance company to issue a written notice of claim rejection and explain the specific reasons. Then, check the insurance policy to verify whether the insured has fulfilled the obligation of truthful disclosure, whether the exemption clauses have fulfilled the obligation of giving warnings and clear explanations according to law, whether the accident falls within the scope of insurance liability and the waiting period, and whether the report and materials are complete. If no agreement can be reached, the insured can seek protection by filing a complaint with the regulatory authority, applying for arbitration, or suing in the people's court with jurisdiction in turn. According to Article 24 of the Insurance Law, the insurer shall issue a notice and explain the reasons within three days from the date of determination; according to Article 17, the clauses exempting the insurer from liability shall not take effect if no warnings or clear explanations are given. The statute of limitations for life insurance is five years, and for other types of insurance, it is two years. It is essential to assert rights in a timely manner. For more details, please refer to the following link:Financial capital and cross-border legal services involving foreign affairs.

1. Problem background and typical scenarios

The insured has paid premiums for many years, but after an insured event occurs, they receive a notice of denial of compensation. This is the most common conflict in insurance consumer disputes. Typical cases include: health insurance denying compensation due to the insured failing to disclose their past medical history before purchasing the policy, but the insured claims that the salesperson filled in the application on their behalf and did not inquire about this medical history; car insurance denying compensation due to exemption clauses such as hit-and-run, drunk driving, and driving without a license; accident insurance having disagreements over whether sudden death, heatstroke, and food poisoning qualify as accidents; property insurance denying compensation due to failure to truthfully declare the value of the insured item or failure to notify the insurer of a significant increase in the risk level; and claims being denied due to incomplete claim materials or exceeding the reporting time limit. Disputes often stem from insufficient disclosure during the insurance application process, misunderstandings of exemption clauses, and miscommunication during the claims process. Victims often give up on seeking justice because they are unfamiliar with the clauses.

II. Key points of contention

  • Provide accurate information about the border: Whether the insured has provided accurate information about the matters inquired about. Pre-existing conditions that have not been inquired about generally do not constitute a failure to provide accurate information. If the salesperson fills in the information on behalf of the insured or induces them to omit to report, the responsibility for this will often lead to disputes.
  • Effect of Disclaimers: According to Article 17 of the Insurance Law, disclaimers must be clearly stated and explained to the insured, otherwise they will not take effect. This is the core of the defense against claims denial in health insurance and accident insurance.
  • Accident qualification: Whether it belongs to an accident, the scope of insurance liability, and agreements such as the waiting period, deductible, and compensation ratio directly determine whether a claim will be paid out or not.

III. Professional analysis by Henglue Lawyers

Henglue Lawyers found in handling insurance claims disputes that the key to winning or losing a large number of refusal-to-pay disputes lies in whether the exemption clauses were truly explained and notified to the insured. According to Article 17 of the Insurance Law and Articles 11 and 13 of the Interpretation of the Supreme People's Court on Several Issues Concerning the Application of the Insurance Law of the People's Republic of China (II), the insurer must make sufficient notifications of the exemption clauses on the insurance application form, insurance policy, and other documents, and provide clear explanations to the insured in writing or orally. Otherwise, the clauses will not become part of the contract and will not take effect. Courts usually require insurers to bear the burden of proof for having provided such notifications and explanations. In practice, simply using bold fonts or stating "see the clauses for details" is often insufficient to prove that clear explanations have been provided, especially for ordinary consumers who need detailed explanations of professional terms. In addition, the rule of unfavorable interpretation of standard clauses (Article 30 of the Insurance Law) often favors the insured in disputes. For cross-border insurance and foreign-funded insurance policies, it is also necessary to take into account the relevant provisions of the Insurance Law and the Foreign Investment Law of the People's Republic of China. 恒略律师在办理保险理赔纠纷中发现，拒赔纠纷的胜负手在于免责条款是否真正向投保人提示说明。根据《保险法》第17条和《最高人民法院关于适用〈中华人民共和国保险法〉若干问题的解释（二）》第11条、第13条，保险人对免责条款须在保险单、投保单等凭证上作出足以引起注意的提示，并以书面或口头形式向投保人作出明确说明，否则该条款不成为合同内容、不产生效力；法院通常要求保险人对已提示说明承担举证责任。实践中，仅以加粗字体、笼统载明详见条款往往不足以证明已作明确说明，特别是对普通消费者而言，专业术语需解释到位。此外，格式条款不利解释规则（《保险法》第30条）也常在争议中向被保险人倾斜。涉及跨境保险、外资保单的，还需结合相关法律法规进行分析。Foreign-related cross-border legal servicesDetermine the jurisdiction and applicable law.

IV. Practical suggestions and legal basis

At the legal basis level: Article 22 of the Insurance Law stipulates that insureds and other parties shall provide claim materials in a timely manner; Article 23 stipulates that insurers shall verify the claim promptly after receiving the request, and in the case of complex circumstances, the verification shall be completed within 30 days (except as otherwise agreed in the contract), and the insurer shall pay the compensation within 10 days after reaching a compensation agreement; Article 24 stipulates that the insurer shall notify the insured in writing and explain the reasons for refusing to pay the compensation; Article 26 stipulates that the statute of limitations for life insurance is five years, and for other insurance it is two years, starting from the date when the insured knows or should know that the insured event has occurred; Article 30 establishes the rule of unfavorable interpretation of standard clauses. Practical advice: Report the accident to the insurer as soon as possible after the occurrence of the insured event, and keep the medical records and accident certificates; after receiving the notice of refusal to pay the compensation, check the clauses and the information provided, and request a written explanation of the reasons; first negotiate with the insurance company, and if unsuccessful, complain to the insurance dispute mediation organizations, regulatory authorities, or apply for arbitration or litigation; pay attention to the statute of limitations and consult as soon as possible.Creditor-debtor relations and enforcement case servicesIt is possible to evaluate the execution.

5. Henglu Law Firm's Reminder

Insurance claims denial is not solely determined by the company. Most denial disputes have room for negotiation, with the core issues lying in the effectiveness of contract clauses, the obligation to provide information, and the allocation of evidence. Henglue Law Firm advises policyholders to systematically preserve all materials after an insured event and not to hastily accept the denial notice upon receipt. They should first seek professional judgment on whether the denial grounds are valid. For circumstances such as insufficient disclosure of exemption clauses or agents filling out notifications on behalf of policyholders, they should actively assert their rights. They should rationally choose among complaint, mediation, or litigation channels and strictly adhere to the statute of limitations. For more insurance disputes and financial consumer protection, please visitBeijing Henglue Law FirmUnderstand the processing experience.

VI. Frequently Asked Questions

Q1: If the insurance company refuses to pay the claim, are they required to provide me with a written notice?

A written notice should be issued and the reasons explained. According to Article 24 of the Insurance Law (amended and implemented on April 24, 2015), after the insurer makes a determination in accordance with Article 23 of this Law, if the claim does not fall within the scope of insurance liability, the insurer shall, within three days from the date of making the determination, issue a notice of refusal to compensate or pay the insurance benefit to the insured or the beneficiary, and explain the reasons. This means that an oral refusal to compensate does not comply with the regulations. The insured has the right to request a written notice of refusal to compensate, and the reasons stated in the notice are also the basis for determining whether the refusal to compensate is valid. If the insurance company merely refuses to compensate vaguely by phone or text message without explaining the specific clauses and facts, the insured may claim procedural defects on this basis and require the other party to bear a heavier burden of proof in complaints or litigation.

Q2: The insurance company said I failed to disclose my medical history truthfully and denied my claim. Is that legal?

It depends on the circumstances of the inquiry and explanation. According to Article 16 of the Insurance Law, the insured has the obligation to provide truthful information, but this obligation is limited to the scope of the insurer's inquiry. If the insurance company refuses to pay compensation on the grounds that the insured failed to disclose relevant information, it must prove that it has specifically inquired about the insured's medical history and that the insured was aware of this history. If the insurance agent filled out the application form on behalf of the insured without inquiring about all relevant items, or if the insured genuinely did not know about the relevant circumstances, it would be difficult to determine that the insured failed to provide truthful information. Moreover, even if it is established that the insured failed to provide truthful information, the insurer should exercise the right to rescind the contract within 30 days from the date it becomes aware of the grounds for rescission, and the contract cannot be rescinded if it has been in effect for more than two years (the non-contestability clause). It is recommended to obtain the audio recording of the insurance application, the insured's signature on the insurance application form, and the inquiry records to prove that the failure to inquire or disclose was unintentional, and to claim that the refusal to pay compensation is invalid on this basis.

Q3: The insurance company never mentioned the disclaimer clause to me. Can I refute their decision to deny compensation?

There's a high possibility of this. According to Article 17 of the Insurance Law, for clauses in insurance contracts that exempt insurers from liability, insurers shall provide a reminder on the application form, insurance policy, or other insurance certificates when concluding the contract, and explain the content of the clause to the insured in writing or verbally; if no reminder or clear explanation is provided, the clause shall not take effect. If the insurance company cannot prove that it has provided a reminder and clear explanation of the exemption clauses to you, the relevant exemption clauses cannot be used as a basis for refusing to pay compensation, and you can request compensation according to the insurance liability. When protecting your rights, you need to collect evidence such as communication records during the application process, whether the application form contains a reminder, and whether the salesperson has provided an explanation; the insurance company bears the burden of proof for having provided a reminder and explanation, and if it cannot provide evidence, it shall bear adverse consequences. If necessary, you can refer to the relevant provisions of the Insurance Law for further guidance.Special services and other case-related servicesAdvance the litigation process.

Q4: After the claim is rejected, should I file a complaint first or sue directly?

It is recommended to proceed in a step-by-step manner: first negotiate, then file a complaint, and finally initiate legal action as needed. During the negotiation stage, you can request the insurance company to reassess and respond in writing, clarifying the focus of the dispute. If the negotiation fails, you can file a complaint with the insurance company's complaint channels, mediation organizations of insurance industry associations, or report violations of sales regulations and lack of adequate explanations to financial regulatory authorities. Complaints against procedural violations are typically effective and cost-effective. For professional disputes involving the validity of exemption clauses or the classification of accidents, or for large-scale disputes that fail to reach a settlement through mediation, you should resolutely file a lawsuit in a court with jurisdiction and leverage the burden of proof rules in insurance disputes (the insurance company bears the burden of proof for explanations and reasons for refusing to pay) to secure a favorable outcome. Regardless of the path chosen, all actions should be initiated within the two-year or five-year statute of limitations to avoid losing the right to seek legal redress.

Q5: After two years, can the insurance company still refuse to pay the claim on the grounds that the insured failed to disclose the relevant information?

Generally, the contract cannot be terminated, but the settlement of claims still depends on the insurance liability itself. According to the incontestable rule in Article 16 of the Insurance Law, if the contract has been in effect for more than two years since its establishment, the insurer shall not terminate the contract; if an insured event occurs, the insurer shall bear the liability for compensation or payment of insurance benefits. This means that even if the insurance company discovers that the insured failed to provide truthful disclosures before the application, it cannot terminate the contract and refuse to pay compensation based on this after more than two years. However, it should be noted that this rule applies to the right to terminate the contract and refuse to pay compensation. If the accident itself does not fall within the scope of insurance liability (such as not being an accident or not being covered by the protection items), the insurance company can still refuse to pay compensation based on the scope of liability; and the starting point of the two-year period is the date of the contract's establishment, not the date of the insured event. It is recommended to keep the date of the contract's establishment and payment records, and check whether the insured event falls within the incontestable period when encountering refusal to pay compensation.

The above content is based on the compilation of judicial practices in the Beijing area. The facts of individual cases and the jurisdiction of the court may affect the conclusions. Welcome to consult Henglue Law Firm about specific situations.

If you are facing similar problems, it is recommended that you consult a professional lawyer as soon as possible with the evidence materials, so as to avoid missing the statutory time limit. →Financial capital legal services·Beijing Henglue Law Firm