隨著科學及社會經濟的進步，人類所遭受的外來意外傷害事故日漸增多。根據台灣保險事業發展中心針對人壽保險業被保險人死亡原因的調查結果顯示，意外事故高居第二位，亦因如此，國人對於傷害保險之潛在需求日益增長。時至今日，傷害保險已與傳統的人壽保險、產物保險成鼎足之勢。然而，因傷害保險理賠爭議涉訟的件數亦隨之增加，亦表示傷害保險本身同時也存在著許多爭議，實有研究之必要與價值。根據目前傷害保險的理賠爭議分析，大多集中於意外傷害認定相關的爭議問題，即「意外傷害」構成要素的意涵、因果關係及舉證責任的分配等。本文的主軸亦集中於此三項爭議問題作探討。 傷害保險事故為何及是否發生，影響保險人是否應負保險金給付責任，故如何認定傷害保險之保險事故即屬重要，亦為保險法第一百三十一條規範之主要目的，實有探究之必要。而除了傷害保險之保險事故應如何認定之外，認定損害之發生是否係導因於傷害保險之保險事故，亦即傷害保險之保險事故是否與損害之間具有因果關係，亦為是否須使保險人負保險金給付責任之要件之一，自亦應予說明。又訴訟中，應由何人就引起損害之事故屬於傷害保險之保險事故負舉證責任，亦影響當事人及利害關係人之權益甚深，實有討論之必要。是以，本文即針對傷害保險事故之認定，因果關係之判斷及傷害事故之舉證責任分配為分析，並附帶說明保險實務目前對於傷害保險常見之爭議問題所持之見解和趨勢。

保險已成為現今社會一重要經濟制度，與證券及銀行共同為金融支柱。而保險已成為每個人生活的必需品，扶助很多遭遇突然事故或災變的家庭度過難關。教科書或文章已經說了很多保險是自助人助的論述。國人從早期對保險的排斥，到現在台灣保險覆蓋率世界第一，每人平均擁有約三張保單，即可證明國人對保險的接受度已經提高。 但依財團法人消費金融評議中心統計，前述金融三大支柱中，以保險的爭議最多。在2015年，產、壽險業申訴及評議案件占整體均為20%及60%以上，而銀行約在10%上下。究其原因，乃保險之經營技術較為特殊，且其為無形「產品」消費者若欲感受保險的存在，幾乎是在理賠階段。而理賠終究有不符合條件之情況發生；再者，消費者與保險公司理賠認定認知差距亦是爭議所在；最後，(保險)消費者主觀意念認為購買保險就是為了發生事故時能得到理賠，故更加深與保險公司間之對立。尤有甚者，以詐欺手段取得保險金，在申請與審理間，保險公司付出相當大的成本查證，但同時也因處理費時而造成客戶不滿(關於『保險詐欺』壽險理賠先進及前輩已有多篇文章論述，且非本文主題，故不予贅述，或容不才爾後以專文研究)。 本人在壽險業界任理賠人十有七年，有感理賠爭議來自三大類：一、壽險：以違反告知義務被保險公司解除契約之爭議為大宗；二、健康保險：此又可分為二類(一)手術爭議及(二)是否有住院必要之爭議。近年則以(二)為大宗；三、傷害險：在業界，傷害險的爭議件數並非最多，但所造成的影響卻為最大。本文以傷害險為研究主題，係以所造成的影響最大為發想；另外，保險法第一三一條所規定之文義是否足以弭平傷害險爭議(尤其在經過多次條文修正後)。從諸多案件中可以發現，一般人對保險法第一三一條條文「I傷害保險人於被保險人遭受意外傷害及其所致殘廢或死亡時，負給付保險金額之責。II前項意外傷害，指非由疾病引起之外來突發事故所致者。」常有誤解，將之解釋為「非疾病即屬意外」顯然解讀錯誤！蓋若「非疾病即屬意外」此一論點成立，則按邏輯將無法解釋「老邁」身故此一自然現象(雖然最高法院民事判決一○三年度台上字第六一二號有稱『按意外傷害保險係承保意外傷害所致之損失，凡傷害或死亡之原因，非罹患疾病、細菌感染、器官老化衰竭等身體內部因素所致，而係外來、偶然等不可預見之事故所生，除保險契約另有特約不保之事項外，均為承保範圍內之意外事故。)按判定是否符合保險上之意外傷害，不能僅僅以「非疾病即屬意外」一語帶過，因為它還必須符合突發、偶然、不可預料等要件。 另外，當被保險人受到意外事故而致傷、殘或死亡時，而傷害結果摻有疾病因素「貢獻」其中時；或承保事故與非承保事故互有因果關係時，該次傷害結果得否認定為傷害保險之承保事故，則必須運用「近因原則」加以判斷。 保險人因承保事故發生而有給付責任，為因契約而成立「債」之關係。但事故是否為承保範圍，則為關鍵所在。於壽險，生存、死亡或殘廢理賠，認定較為簡單；但於傷害保險，被保險人是否因為條款約定之「意外傷害事故」致成傷害，因為事過境遷，事實很難認定。於法院繫屬時，被保險人(受益人)與保險公司間之攻防，即與舉證責任息息相關。若有一方舉證不能，即有受訴訟不利益風險。 / Insurance is now a major part of the economy system. It plays an important role like stocks and bonds, or banks in the financial industry and it is now essential in our everyday life. Insurance helps the families that experienced accidents or tragedies overcome the difficulties. Lots of textbooks and articles have let us know that the insurance is the statement of cooperation. People in Taiwan had been rejecting the insurance in early days; however, until now, the usage rate of insurance in Taiwan has become the top class in the whole world with the average three policies per person, which can prove that insurance is more acceptable nowadays. Nevertheless, according to the research of Financial Ombudsman Institution, among the three important roles in the financial industry, Insurance, Stocks and Bonds, and Banks, Insurance is the most controversial. In 2015, the percentage of appeals and arbitration of Non-life and life insurance industry are over 20% and 60%. However, the banks have only around 10%. To explain this kind of circumstance, it is because that the value proposition of insurance industry is more special than others. The products of the insurance, the policies, are mostly intangible, which that the customers cannot recognize the product easily and only when the claims have been settled, the customers can reach the product directly. But, the claims are not always settled as long as the conditions are not met. Moreover, the recognition of the claims are not the same from different points of view and that is the controversial point. Lastly, the customers regard the policies as the guarantees of the claims, which mean that they think once they bought the policies, the claims will be settled anyway as long as the accidents happen. Therefore, this thought strengthens the opposition of the customers to the companies. Furthermore, some people try to get the settlement using fraudulent methods. Such kind of activities costs the companies a lot to verify during the phase of application and processing. At the same time, due to the investigation, it also brings the dissatisfaction of the customers. I have been working in the department of claim of life insurance for 17 years and I have learnt that the controversies are basically from three categories, Life Insurance, Health Insurance, and Injury Insurance. For Life Insurance, most of the conflicts are from the obligation of disclose of the customers, and if the obligation is not fulfilled, the company will terminate the contract in the end. For Health Insurance, it can be categorized into two, one is surgery conflicts and the essentiality of being hospitalized and most of them are the second one. For the last, Injury Insurance, it doesn’t have the most cases of the conflicts, but it is the most influential. This paper focuses on Injury Insurance due to the characteristics of most influential and whether the definition of Article 131(A personal accident insurer is obligated to pay the insured amount when the insured suffers injury by accident, or becomes disabled or dies on account of such injury. The term "injury by accident" as used in the preceding paragraph refers to physical harm caused by unforeseen external events other than illness.), Insurance Act, can eliminate the conflicts of Injury Insurance or not. From lots of cases of Injury Insurance, normal people are not clear about the Article and misunderstand the contents as either disease or accidents. If the statement is true, then the natural death cannot be explained as an accident. The recognition of an accident cannot solely by such a brief definition because it has to meet the conditions of “Sudden”, “Accidental”, and “Unpredictable”. In addition, when the insured is injured, disabled, or dead caused by accidents and the outcome of the injury contains the elements of disease, or when the insured peril and the non-insured peril have causal relationships, whether the outcome can be recognized as the insured peril or not depends on the “Proximate Cause”. The insurer has the obligation to pay once the insured peril occur because of the contract and form the relationship of debt. However, the key of the issue is whether the accident is in the scope of the insured peril. In Life Insurance, the recognition of survival, death, or disability is simpler compared to Injury Insurance which contains more uncertain elements. On the other hand, in Injury Insurance, whether the insured is injured because of the insured peril or not is not easy to verify due to the fact is not the same as it happened. During the suit, the burden of proof has a great relationship with the defendant and the plaintiff. As long as one cannot provide any proof, he has the risks of losing the suit.

國內保險經營，行銷通路長久以來均以業務人員直銷通路及經代通路為首要業務來源，近年來新興保險業務通路崛起，最被看好的為電話行銷通路、網路通路及銀行行銷通路，其中影響最鉅者即是銀行行銷通路。 本研究乃針對銀行通路行銷傷害保險之效益與職業團體通路、直接業務通路、經代通路、電話行銷通路、網路通路與客服中心八種通路比較，對於保險公司保費收入與理賠支出面的影響。研究結果顯示 (一) 銀行通路損失率顯著低於直接業務通路的損失率，是保險公司可以加強銀行通路業務 (二) 電話行銷通路及網路通路在損失率比銀行通路顯著較低，為值得注意之新興通路 (三) 電話行銷通路及網路通路在保險費比銀行通路顯著較低，可見傷害保險業務在通路尚有極大發展空間 (四) 職業團體通路、直接業務通路與經代通路之損失率相對偏高，個案公司應積極改善此通路績效

傷害罪的研究，在我國學說實務上對於特定的議題可能有所分歧，但原則上已然有一定的研究成果與結論，對於身體或是健康的定義，或者是所涵攝的範圍等等。然而隨著社會發展，以及對於個人身體期待有更為完整的保護，除了生理機能上的傷害以外，對於心理、精神、或是情緒上的傷害，是否能夠被劃歸於傷害罪的保護範圍，也應有其討論空間。 本文試圖由保護法益出發，討論心理傷害在身體法益的角度下其存在的可能，如果可能存在，則在現行的條文下應該做如何的解釋。這並不是一個純粹學術的討論，而是一個貼近社會每個個體的議題，每個社會個體在社會中的活動，都可能造成他人心理或是情緒上的不愉快；相反的，也可能因為他人的行為而有心理或情緒上的不愉快。這些事實每天重複的發生在我們周遭，重點在於是否有注意到這些心理傷害存在，以及如何給予心理傷害評價。 肯認心理傷害的概念是存在後，如果要作更細緻的分析，就必須先定義心理傷害的概念，去尋找在哪些情況之下，會成為具有法律意義的心理傷害，而為傷害罪之保護範圍。將其具體化，也就是心理傷害的傷害結果是必須符合一些標準的，如果欠缺標準，則會使心理傷害的概念浮動，而可能過度擴張其範圍，故若該結果欠缺實質的情緒傷害、或是未使被害人的反應非屬正常範圍等，則不認為其為心理傷害，而可能是一種負面的情緒反應而已。 心理傷害因為其本質較為特別，是何種行為導致心理傷害結果的存在，也就是行為與結果之間的因果關係並不甚清楚。其理由在於，在心理傷害的情形，特定行為是否確實造成心理傷害結果並不是客觀明顯可見的，是以一個心理傷害結果的存在，是由A行為或是B行為所導致，或是由A、B數行為一同造成，除非有明確的事實證據可以作為依據，否則因果關係的建立上，都只能透過人類經驗的累積作為參考依據，而無法使用條件理論來作為判斷標準，是以在此情形下，透過人類經驗而建立因果關係的假設因果關係理論，在論理上似乎會是比較實用也比較合理的標準。 在因果關係的確立後，同時必須考量該結果是否可以歸責於行為人，如果該行為在社會上是被允許的，則即使該行為可能有造成他人心理傷害的風險，該風險就應該被容許而會是容許風險。而在社會中因為有親疏程度不同之人際關係，如果人與人之間的關係較為緊密，在社會共識上會提高容許風險的門檻，而擴大容許風險的範圍，在結論上，就會是該行為雖然造成心理傷害結果，但是因為該行為本身帶有傷害結果的風險是社會所已經認識且允許的，是以即使該風險確實實現，社會也不會予以處罰。 關鍵字：傷害、心理傷害、負面情緒、情緒傷害、實質情緒傷害、正常範圍、人類經驗、假設因果關係、容許風險 / The researches of assault and battery may exist difference in specific issues between theories and practice, but in general, the researches have got some results and had conclusions, like the definition of body or health, or the area which assault and battery including. However, due to the developing of the society and the more desire to protect individual body, except the harm to the physical functions, if the harm to mind or emotion could be classified as the range of assault and battery may be worth discussing as well. This thesis tries to start from the legal interest(Rechtgut), to talk about the possibility of mental injury included in the legal interest of body. If the legal interest of body include the mental harm, then how to explain the articles which are currently in effect. This is not a pure academic discuss, but a issue which close to every individual in society. The activities of individuals in society may cause mental or emotional unpleasantness. On the contrary, mental or emotional unpleasantness might be caused by other’s behaviors too. Those facts around us happen repeatedly everyday and the importance is whether we noticed the mental harm exist or not, and how to appraisal it. After confirming the notion of mental harm or injury exist, if try to analyze more detailed, defining the mental harm notion is the first step we should take and looking for under what kind of situations the notion of mental harm will become meaningful in legal system. Specifically, which means the results of mental harm must conform with some standards. If lacking of standards, the notion of mental harm will be vague, and the result of the vagueness, it might broaden the range excessively. So if the results lack of substantial emotional harm, or didn’t make victims’ reactions out of normal range, then we don’t admit the result is a mental harm, but a negative emotion. Because mental harm has special quality, the question is which behavior leads to the results of mental harm, and the causation between behavior and result is not clear enough. The reason is that in the situation of mental harm, if the specific behaviors surly cause the result of mental harm can’t be discovered obviously and objectively. As the result, the existence of a result of mental harm is caused by behavior A or B, or is caused by A and B, except we have clear facts and proofs to be reference materials, or we only can apply the accumulation of human experience to the construction of causation and we can not use condition theory(Bedingunstheorie) as the standard to determine the causation. Thus, the theory of hypothesized causation constructs the causation through the human experience seems more practical and reasonable standard. When the causation have been constructed, after that, the question is that if the defendant should be blamed for the result should be considered as well. If the behavior is allowed in the society, then even if the behavior may bring about the risk of mental harm of the others, but the risk shall be allowed or endured and is an allowable risk(das erlaubte Risiko). And the relationships between people are not always as any others, if the relationship is closer, the common consensus of society will raise the line of allowable risk and broaden the range of allowable risk. In conclusion, although the behavior leads to the result of mental harm, the behavior companies the risk of the result of mental harm is recognized and allowed by society, so even the risk occur in deed, society will not punish the behavior. Key Word: assault, battery, harm, injury, emotional harm, mental harm, emotional injury, substantial emotional harm, normal range, causation, allowable risk

本文共分三個部分。本文第一部分試圖就博格（Thomas Pogge）對世界貧窮的關懷，所提出的理論做出說明與釐清。博格的理論試圖指出並說明，因為諸富裕國家之國民透過當今不正義的制度，而造成世界貧窮此一傷害，所以應為這樣的行為承擔責任。本文將在第一部分對其理論中「不正義的制度」做出釐清，並做討「制度是否能作為一個主動能動者」此一問題前的釐清與說明。 本文第二部分則是承接第一部分的分析，指出「制度」並非主動能動者，「制度傷人」亦須透過行為者的行為才能傷人。本文第二部分作為全文核心，將說明博格的理論為何需要對制度及行為者做出區分，而行為者又如何造成傷害。並將指出在博格的理論中，缺乏這部分的說明，導致其理論可能會得到博格本人所不願接受的結論。 本文第三部分則是試圖指出博格的理論會失敗，是由於他試圖以消極責任的概念來做人權的請求，而這將導致他的理論中，勢必談論到行為者的面向，而在此面相，尚有待經驗研究方能確定。而在本文第三部分將就博格的理論與漢娜鄂蘭（Hannah Arendt）所論及有關「罪與責任」的理論做比較，並用和博格進路不同的楊（Iris Young）的觀點，來指出無法採取博格的理論進路，來得到他所希望的結論。

(平成15年度理学療法奨励基礎研究)

(理学療法基礎系II)

一般當討論到保險的時候，只討論到保險的承擔風險的功能，也就是故事到理賠完畢就結束了，但很少提及到理賠完畢之後的故事。本文的病人醫療傷害保險強調的是理賠完畢後的故事。發生醫療傷害時，病人之保險公司理賠完病人取得代位求償權之後，就能將原本由許多病人各自處理的醫療糾紛集中由病人之醫療傷害保險公司處理。因為案件數量大，經由學習、標準化可以降低交易成本。而交易成本的降低，可以使醫師與病人雙方都得到好處，達成雙贏的局面。

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第20291号 / 社医博第80号 / 社新制||医||9(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川上 浩司, 教授 柳田 素子, 教授 長船 健二 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

傷害保險之機能不但隨著現代社會之需要而變化，而傷害保險事業也可說已經蓬勃發展。然而，有關傷害保險之爭訟日益增多，尤其在保險事故的認定上，更是屢屢出現各種爭議，並逐漸有類型化之趨勢。 為此，立法院於民國九十二年一月二十二日，增訂保險法第一百三十一條第二項規定：「前項意外傷害，指非由疾病引起之外來突發事故所致者。」徵其目的，乃在於透過法律位階明文定義傷害事故，以期定紛止息，然在其他保險先進國家，此種立法例極為鮮見。 有鑑於傷害保險屬於保障人身意外傷害事故之重要險種，在傷害保險事故之認定上卻爭訟不斷，而上述最新之明文立法方式，是否真能解決紛爭，即有待檢驗。此外，在某些案例中，醫學鑑定報告及法醫學上的判斷雖不可欠缺，但在保險事故的認定與判斷方面，法律整理工作更是前提要件，例如保險事故之要件、舉證責任之歸屬等等。本文即欲引介並檢視其他保險先進國家對意外傷害認定爭議問題之處理方式，以作為我國處理相同爭議之借鏡。