风险管理与保险1428.doc

Principles of Risk Management and Insurance风险管理与保险Major ReferenceGEORGE E1. REJDANinth Edition (2005)高应大金融系 谢坤民 编著PART TWOLegal Principles in Risk and InsuranceChapter 5 Fundamental Legal PrinciplesChapter 6 Analysis of Insurance ContractsChapter5 Fundamental Legal Principles 法定基本原则(一)Principles of Indemnity补偿原则 states that the insurer agrees to pay no more than the actual amount of the loss。保险人所赔偿之金额不超过真正之损失金额。大部份之产物保险契约为损失补偿契约。其目的有二个(1)prevent the insured from profiting from a loss预防被保险人不当得利(2)reduce moral hazard减少道德危险(1)Actual Cash Value实际现金价值 which is defined as replacement cost less depreciation, supports the principle of indemnity since it is designed to prevent profiting from insurance 1.Replacement Cost less depreciation 2.Fair Market Value公平市价(2)Exceptions to the principles of indemnity 例外 1.Valued Policy定值保单：A valued policy pays the face amount in the event of a total loss. 全部损失发生以保险金额赔付 Thus, it is an exception to the principle of indemnity since the amount paid could be more than what the property is actually worth 2.Replacement Cost Insurance：Replacement cost insurance means there is no deduction for depreciation, which allows the insured to be made better off by receiving new property for old no deduction for depreciation 3.Life Insurance is a valued policy为定额保险A life insurance policy is also an exception to the principle of indemnity because it is a valued policy that pays a stated sum to the beneficiary upon the insureds death. It is difficult to determine accurately the value of a human life, and the amount paid may substantially exceed the economic value of the insureds life. The human life value approach gives a crude estimate of how much a persons life is worth, but few people insure their lives fully, and all losses are total. (二)Principle of Insurable Interest 保险利益原则Insured stands to lose financially if a loss occurs State that the insured must be in a position to lose financially if a loss occurs损失发生时被保险人有遭受财务上之损失。 An insurable interest is required in every insurance contract in order to prevent gambling, to reduce moral hazard, and to measure the amount of the insureds loss inproperty insurance. (1)Purposes of an Insurable Interest保险利益存在之目的1.To prevent gambling预防赌博行为2.To reduce moral hazard 减少道德危险3.To measure the amount of the Insureds loss in property insurance在财产保险中衡量被保险人之损失金额 (2)Examples of an Insurable Interest1.Property and liability Insurance产物保险A.Ownership of property所有权 owners of property will lose financially if their property is damaged or destoryedB.Potential legal liability法律责任 The firm may be legally liable for damage to customers goods cause by the firms negligenceC.Secured creditors债权关系 A commercial bank that lends money to buy a house has an insurable interest in the property of mortgageD.Contractual right契约权利 a business firm that contracts to purchase goods from abroad on the condition that they arrive safely has an insurable interest in the goods.2.Life Insurance寿险 A.Family or Marriage家庭或婚姻 a husband can purchase a life insurance policy on his wifes life and be named as beneficiary. B.Pecuniary interest金钱利益 Even when there is no relationship by blood or marriage, one person may be financially harmed by the death of another. C.我国保险法第16条之规定要保人对於下列各人之生命或身体，有保险利益：一、本人或其家属。二、生活费或教育费所仰给之人。三、债务人。四、为本人管理财产或利益之人。 (3)When Must an Insurable Interest Exist？保险利益何时存在 1.In property insurance：must exist at the time of the loss存在於损失发生时。Reasons:A.most property insurance contracts are contracts of indemnity.B.you may not have an insurable interest in the property when the contract is first written but may expect to have an insurable interest in the future, at the time of possible loss. 2.In life insurancemust be met only at the inception of the policy, not at the time of death存在於契约订立时，而非被保险人死亡时。ReasonA.life insurance is not a contract of indemnity but is a valued policy that pays a stated sum upon the insureds death.B.the beneficiary has only a legal claim to receive the policy proceeds, the beneficiary does not have a show that a loss has been incurred by the insureds death.就算要保人与被保险人事后离婚，只要要保人继续交付保费，且被保险人愿意继续当被保险人，则当被保险人死亡时，则受益人仍然可以领取保险金(Proceed) 。(三)Principle of Subrogation代位求偿原则 Insurer is entitled to recover from a negligent third party any loss payments made to the insured.Substitution of the insurer in place of the insured for the claiming indemnity from a third person for a loss covered by insurance承保损失发生而被保险人对第三人有求偿权 ，保险人赔付后取得对第三人之求偿权。(1) Purposes of Subrogation1.prevents the insured from collecting twice for the same loss预防被保险人双重得利2.hold the guilty person responsible for the loss对损失有责任者不因保险而免责3.hold down insurance rates降低保险费率(2)Importance of Subrogation重要规定1.the insurer isentitled only to the amount it has paid求偿金额以赔付金额为限2.the insured cannot impair the insurers right被保险人不能损害到保险人之权利3.the insurer can waive its subrogation rights 保险人可以放弃代位求偿权4.does not apply to life insurance and most health insurance不适用人寿保险及大部份之健康保险5.the insurer cannot subrogate against its own insureds不能对被保险人行使代位求偿权(四)Principle of Utmost Good Faith 最大诚信原则 A higher degree of honesty is imposed on both parties to an insurance contract than is imposed on parties to other contract比其他契约，要求保险契约双方之较高诚实程度。我国民法1488条行使权利，履行义务，应依诚实及信用方法 。Areas of application-legal doctrines of misrepresentation, concealment, and breach of warranty(1)Representation告知或说明 statements made by the application for insurance要保人之陈述事项。如年龄、体重、身高、职业、健康状况、家庭病史等。当Representation是下列三种情形时，则保险契约是无效的(voidable) 。1.material重要的：if the insurer knew the true facts, the policy not have been issued or it would have been issued on different terms保险人如知道事实则不签发保单或保单条件不同2.false错误的：statement is not true or is misleading不真实或误导3.relied on by the insurer保险人信以为真the insurer relies on the misrepresentation in issuing the policy at a specified premium保险人依赖陈述事项在特定保费来出单。(2)Concealment隐瞒 intentional failure of the applicant for insurance to reveal a material fact to the insurer投保时故意不揭露重要事项1.the concealed fact was known by the insured to be material 被保险人知情其为重要事项2.the insured intended to defraud the insurer被保险人有意欺骗保险人(3)Warranty保证：a statement of fact or a promise made by the insured, which is part of the insurance contract and must be true if the insurer is to be liable under the contract被保险人之陈述或承诺其为真实，且为契约之一部份。违反保证事项，一般保险人主张契约无效，而不予理赔。 (4)Requirements of an insurance Contract保险契约成立之要件1.Offer and acceptance要约及承诺In most cases, the applicant for insurance makes the offer, and the company accepts or rejects the offer.产物保险之要约及承诺可以是口头或书面，人寿保险皆以书面为之。产物保险为提供正式保单签发前之保障，一般尚有暂保单(Binder)之签发，人寿保险则无。2.Consideration对价The value that each party gives to the other.A.Insureds consideration generally is payment of the first premium.B.Insurers consideration is the promise to perform the contract.要保人付保费，保险人於约定事故发生负赔偿责任。3.Competent parties当事人有法定能力 This means the parties must have legal capacity to enter into a binding contract. Minors normally are not legally competent to enter into binding insurance contracts.The insurer generally must be licensed to sell insurance, and the insurance sold must be within the scope.4.Legal purpose合法目的 An insurance contract that encourages or promotes something illegal or immoral is contrary to the public interest and cannot be enforced非法或不道德且违反公共利益契约无效。(5)Characteristics of insurance contract保险契约之特性1.Aleatory contract射幸契约 where the value exchanged may not be equal but depend on an uncertain event契约所生之利益不具有等价关系，而系於不确定事件发生。具有等价关系之契约，称为交换契约(Commutative Contract)2.Unilateral contract单务契约means that only one party makes a legally enforceable promise只有一方负有法定义务。如双方皆负有义务，称为双务契约(Bilateral Contract) 。most commercial contract are bilateral contract in nature. Each party makes a legally enforceable promise to the other party. 3.Conditional contract条件契约That is, the insurers obligation to pay a claim depends on whether the insured or the beneficiary has comply with all policy conditions.Conditions are provisions inserted in the policy that qualify or place limitations on the insurers promise to perform. 保险人是否负给付义务，须视被保险人或受益人是否配合契约之条件。4.Personal contract对人契约 which means the contract is between the insured and the perty insurance policy cannot be validly assigned to another party without the insurers consent.Thus, the insurers consent is normally required before a property insurance policy can be validly assigned to another party.在产物保险要保人投保时，须经保险人接受，其关於被保险人之特性(character)、道德(moral)、信用(credit)，必须符合其核保标准。未经保险人同意其契约不得转让(assignment) 。在人寿保险其保单可自由转让，because the assignment does not usually alter the risk or increase the probability of death因为其转让并不会改变其风险或增加其死亡率。5.Contract of adhesion附合契约 the insured must accept the entire contract, with all its terms and conditions.被保险人必须接受整个契约包括其所有条件。虽然契约可以批单(endorsement)变更之，但批单内容也是由保险人所订定。如契约内容有疑义，以作有利於被保险人为原则。(6)Waiver and Estoppel弃权与禁止抗辩1.Waiver-voluntary relinquishment of a known legal rightWaiver弃权 as the voluntary relinquishment of a known legal right保险人放弃知道之法定权利，放弃后就不得否认应理赔事项。2.Estoppel-representation of fact made by one person to another person that is reasonably relied on by that person to such an extent that it would be inequitable to allow the first person to deny the truth of the representationEstoppel禁止抗辩 如要保人於契约订立时有告知不实，且其期间已经过两年，则保险人禁止提出抗辩，而解除契约主张不赔(参阅我国保险法第六四条)(五)Key Concepts and Terms禁止抗辩Estoppel附合契约Contract of Adhesion 对价Consideration附条件保费收据Conditional Premium Receipt条件契约Conditional Contract隐匿Concealment交换契约Commutative Contract广泛证据法则Broad Evidence Rule暂保单Binder射幸契约Aleatory Contract实际现金价值Actual Cash Value(五)Key Concepts and Terms补偿原则Principle of indemnity对人契约Personal Contract金钱利益Pecuniary Interest要约与承诺Offer and Acceptance重要事项Material Fact合格之当事人Legally Competent Parties合法目的Legal Purpose不实告知Innocent Misrepresentation默示效力Implied Powers公平市价Fair Market Value明示效力Express Powers(五)Key Concepts and Terms保证或特约Warranty弃权Waiver定值保单Value policy单务契约Unilateral Contract代位求偿Subrogation告知Representation重置成本保险Replacement Cost Insurance最大诚信原则Principle of Utmost Good faith合理期待原则Principle of Reasonable Expectations保险利益原则Principle of Insurable InterestChapter6 Analysis of Insurance contracts保险契约之分析(一)Basic parts of an insurance contract (1)Declarations声明事项1.Nature- statements made by the applicant for insurance2.Purpose- to provide information for underwriting, rating, and identifying who and what is insured and for how much .In property insurance, the declarations page typically contains information concerning the identification of the insurer, name of the insured, location of property, period of protection, amount of insurance, amount of premium, size of the deductible(if any).In life insurance,although the first page of the policy technically is not called a declarations page, it contains the insureds name, age, premium amount, issue date, and policy number.(2)Definitions定义：Key words or phrases have quotation marks(“”) around them.The insurer is frequently referred to as “we,” “our,” or “us”The insuredis referred to as “you” and “your”(3)Insuring agreement承保范围：is the heart of an insurance contract. summarizes the major promises of the insurer.The promises of the insured and the conditions under which losses are paid are described in the insuring agreementTwo basic form of an insuring agreement in property and liability insurance1.Named perils coverage列举式：only those perils specifically named in the policy are covered 仅有列出的危险事故才被承保。2.All Risks coverage(also called an open perils policy)概括式：all losses are covered except those losses specifically excluded. If the loss is not excluded, then it is covered.除了特定之除外事项外，所有损失皆承保在内。All risks coverage is generally preferable to named-perils coverage, because the protection is broader with fewer gaps in coverage.To deny payment, the insurer must prove that the loss is excluded. In contrast, under a named-perils contract, the burden of proof is on the insured to show that the loss was cause by a named peril.(4)Exclusion不保事项There are three major types of exclusions.1.Excluded Perils不保危险事故 The contract may exclude certain perils, or cause of loss.In a homeowners policy, the perils of flood, earth movement, and nuclear radiation or radioactive contamination.In property and liability insurance, most insurance contract exclude coverage for acts of war. The war exclusion clause is important today because of the terrorist attack on the United States on September 11, 2001. 2.Excluded losses不保损失 certain types of losses may be excluded.3.Excluded property不保财产 in a homeowners policy, certain types of personal property are excluded, such as cars, planes, animals, birds, and fish. in a liability insurance policy, property of others in the care, control, and custody of the insured is usually excluded.*Reasons for Exclusions1.Perils not commercially insurable Exclusions are necessary because the peril may be considered uninsurable.2.Extraordinary异常的 hazards involved Exclusion are also used because extraordinary hazards are present.3.Coverage provided by other contracts Exclusion are also necessary because coverage can be better provided by other contract.4.Moral hazard present In addition, certain property is excluded because of moral hazard or difficult in determining and measuring the amount of loss.5.Coverage not needed by typical insureds Exclusions are used because the coverage is not need by the typical insured.(5)Conditions条件provisions in the policy that qualify or place limitations on the insurers promise to perform.In effect, the conditions section imposes certain duties on the insured.If the policy conditions are not met, the insurer can refuse to pay the claim.规范保险人与被保险人之权利义务事项。1.Give notice of loss(寿险)要保人或受益人应於知悉本公司应负保险责任之事故后十日内通知本公司，并於通知后尽速检具所需文件向本公司申请给付保险金。本公司应於收齐前项文件后十五日内给付之。逾期本公司应按年利一分加计利息给付。但逾期事由可归责於要保人或受益人者，本公司得不负担利息。2.Preserve and protect property from further loss or damage(火险)损失扩大之防止遇有本保险契约承保之危险事故发生时，要保人或被保险人应立即采取必要之措施，以避免或减轻保险标的物之损失，并保留其对第三人所得行使之权利。3.Submit proof of loss (6)Miscellaneous provision其他条款In Property and Liability Insurance1.Cancellation clause 终止(火险)对於本保险契约，要保人或被保险人均有终止之权。要保人或被保险人终止契约者，除终止日另有约定外，自终止之书面送达本公司之时起契约失其效力，对於终止前之保险费本公司按短期费率计算。要保人行使前项之终止权，应获得被保险人同意。对於本保险契约，除法律另有规定或本保险契约另有约定外，遇有下列情形之一时，本公司得终止契约：一、保险费未依本保险契约第六条之约定交付时。二、本保险契约生效后未逾六十日时；但保险契约为续保者，不得依本款约定终止。本公司依前项第一、二款终止契约者，应於终止日前十五日通知要保人或被保险人。本公司终止契约后应返还之未满期保险费应按日数比例计算，并於终止生效日前给付。(6)Miscellaneous provision其他条款In Property and Liability Insurance2.Appraisal估价有争议时采用仲裁Arbitration被保险人或其他有保险赔偿请求权之人对於理赔存有争议时，得以仲裁方式解决。其程序及费用依仲裁法及相关法令办理。 3.Assignment转让(车险)保险标的物所有权之移转保险标的物所有权因转让或被保险人破产而移转者，本保险契约仅於所剩余保险期间内继续有效。但若所剩余保险期间超过九十日者，除当事人另有约定外，本保险契约自保险标的物转让或被保险人破产宣告之次日起届满九十日时即行终止。终止前之保险费按日数比例计算。被保险人死亡时，本保险契约仍为继承人之利益而存在。但继承人应通知本公司签批变更被保险人。 (6)Miscellaneous provision其他条款In Property and Liability Insurance4.Other Insurance其他保险其他保险Other Insurance 保险标的物在承保之危险事故发生时，如另有其他保险契约同时应负赔偿责任，本公司应依本保险契约之保险金额与总保险金额之比例负赔偿之责。但本公司得经被保险人请求，先行全额赔付后，依比例分别向其他保险之保险人摊回其应赔付之金额，被保险人应提供必要之协助。(6)Miscellaneous provision其他条款In Property and Liability Insurance4.Other Insurance其他保险复保险Double Insurance 对於同一保险标的物，如同时或先后向其他保险人投保相同之保险，致保险金额之总额超过保险标的物之价值者，要保人或被保险人应立即将其他保险人之名称及保险金额通知本公司。要保人或被保险人故意不依前项规定为通知，或意图不当得利而为复保险者，本保险契约无效。保险费已收受者，本公司不予退还，尚未收受者，本公司得请求交付。本保险契约有善意复保险情形者，本公司得为如下之处理：一、於承保危险事故发生前，本公司经要保人或被保险人通知后，得降低本保险契约之保险金额，并按减低之保险金额及未满期保险期间，比例退还保险费。二、於承保危险事故发生后，仅按本保险契约之保险金额对全部保险契约保险金额总额之比例负赔偿责任。复保险Double Insurance之要件1.同一保险利益2.同一保险事故3.同一保险期间4.与数个保险人订立数个保险契约5.数个保险契约之总保险金额超过保险标的之价值符合上述五项要件称狭义之复保险，而广义之复保险则指第五项要件为数个保险契约之总保险金额未超过保险标的之价值。我国依保险法第三十七条要保人故意不为前条之通知，或意图不当得利而为复保险者，其契约无效。保险法第三十五条复保险，谓要保人对於同一保险利益，同一保险事故，与数保险人分别订立数个保险之契约行为。，保险法第三十八条善意之复保险，其保险金额之总额超过保险标的之价值者，除另有约定外，各保险人对於保险标的之全部价值，仅就其所保金额负比例分担之责；但赔偿总额，不得超过保险标的之价值。 (6)Miscellaneous provision其他条款In Property and Liability Insurance5.Subrogation(火险)被保险人因本保险契约承保范围内之损失而对於第三人有赔偿请求权者，本公司得於给付赔偿金额后，於赔偿金额范围内代位行使被保险人对於第三人之请求权。前项情形，被保险人对第三人有赔偿请求权以外之其他权利时，被保险人同意转让该权利予本公司。本公司就保险标的物之全部或一部以全损赔付被保险人或其他有保险赔偿请求权之人时，被保险人同意转让该已赔付保险标的物之所有权予本公司。 Subrogation代位权之要件1.被保险人对第三人有损失赔偿请求权2.保险人对被保险人已给付赔偿金3.代位范围不得超过赔偿金额4.损害赔偿之标的须一致保险法第五十三条被保险人因保险人应负保险责任之损失发生，而对於第三人有损失赔偿请求权者，保险人得於给付赔偿金额后，代位行使被保险人对於第三人之请求权；但其所请求之数额，以不逾赔偿金额为限。 前项第三人为被保险人之家属或受雇人时，保险人无代位请求权；但损失系由其故意所致者，不在此限。 (6)Miscellaneous provision其他条款In Life and Health Insurance1.Grace Period宽限期分期缴纳的第二期以后保险费，应照本契约所载交付方法及日期，向本公司所在地或指定地点交付，或由本公司派员前往收取，并交付本公司开发之凭证。第二期以后分期保险费到期未交付时，年缴或半年缴者，自催告到达翌日起三十日内为宽限期间；月缴或季缴者，则自保险单所载交付日期之翌日起三十日为宽限期间。约定以金融机构转帐或其他方式交付第二期以后的分期保险费者，本公司於知悉未能依此项约定受领保险费时，应催告要保人交付保险费，其宽限期间依前项约定处理。逾宽限期间仍未交付者，本契约自宽限期间终了翌日起停止效力。如在宽限期间内发生保险事故时，本公司仍负保险责任。(6)Miscellaneous provision其他条款In Life and Health Insurance2.Reinstatement复效 本契约停止效力后，要保人得在停效日起二年内，申请复效。 前项复效申请，经本公司同意并经要保人清偿欠缴保险费扣除停效期间的危险保险费后之余额，自翌日上午零时起恢复效力。 停效期间届满时，本保险效力即行终止，本契约若累积达有保单价值准备金，而要保人未申请垫缴保险费或变更契约内容时，本公司应主动退还剩余之保单价值准备金。(6)Miscellaneous provision其他条款In Life and Health Insurance3.Misstatement of age年龄错误被保险人的投保年龄，以足岁计算，但是未满一岁的零数超过六个月者加算一岁，要保人在申请投保时，应将被保险人出生年月日在要保书填明。如果发生错误应依照左列规定办理。一、真实投保年龄较本公司保险费率表所载最高年龄为大者，本契约无效，其已缴保险费无息退还要保人。二、因投保年龄的错误，而致溢缴保险费者，本公司无息退还溢缴部份的保险费。如在发生保险事故后始发觉且其错误发生在本公司者，本公司按原缴保险费与应缴保险费的比例计算保险金额。三、因投保年龄的错误，而致短缴保险费者，应补足其差额；如在发生保险事故后始发觉者，本公司得按原缴保险费与应缴保险费的比例计算保险金额，但错误发生在本公司者，不在此限。(二)Definition of the “Insure