[흥국화재] ➡ QR코드 P (p24-43)

Ⅳ. 보험금 청구 및 지급절차 안내
후유장해
- 후유장해진단서
※ 발급전 당사 콜센터 또는 지급담당자와 상의하시기 바랍니다.
종합병원
(대학병원)
※ (일반)진단서로 대체 가능한 장해
· 사지절단 : 절단부위, 환자상태 기재, X-ray필름 첨부
· 인공관절치환술 : 수술명, 수술일자 기재
· 비장, 신장적출 : 비장, 신장적출 수술일 기재
의료비,
입원
일당
및
응급실
내원비
자동차
보험처리
- 사고처리확인서(자사 자동차보험 처리시 생략가능)
해당보험사
자동차
보험 미
처리
- 교통사고사실확인원
- 입(통)원확인서(진단명 필수기재)
- 진료비영수증
- 진료비 세부내역서
- 경찰서 미신고시 기타사고 증빙서류제출(초진차트 등)
경찰서
진료병원
면허정지처리비용
- 교통사고사실확인원
- 면허정지 행정처분 확인원(교육必後)
- 운전경력 증명서
경찰서
법원
면허시험장
면허취소처리비용
- 교통사고사실확인원
- 면허취소 행정처분 확인원
- 운전경력 증명서
경찰서
법원
면허시험장
벌금
- 교통사고사실확인원, 약식명령서, 벌금영수증
경찰서, 법원
교통사고합의비용
(중상해 포함)
- 교통사고사실확인원
- 피해자진단서
- 경찰서에 제출된 형사합의서(합의금액 명시), 공소장(미합의시)공탁서 및
피해자 공탁금 출금 확인서
경찰서, 법원
자동차사고
부상
- 자동차보험에서 보상받은 경우
· 해당 자동차보험의 보상처리확인서
- 자동차보험에서 보상받지 못한 경우
· 경찰서에서 발행한 교통사고사실확인원 및 상해등급을 판단할 수 있는 서류
(진단서, 수술기록지 등)
보험사,
병원,
경찰서
◆ 진단서, 통원확인서, 처방전, 진료확인서, 소견서, 수술확인서, 진료차트 등에는 진단명이 기재되어 있어야 합니다.
◆ 필요시 손해조사, 신속한 보험금 지급결정을 위해 보상담당자가 의료정보 열람 위임장(인감날인)/인감증명서를
요청할 수 있습니다.
◆ 척추체 등 운동장해 판정은 운동가능범위(AMA)방식을 적용하나 추간판탈출증(속칭 디스크)의 경우 산정기준이
이와 다르며 운동장해의 경우에도 사고내용에 따라 산정기준이 상이할 수 있습니다.
재해 입증서류 예시
1. 교통사고 : 공공기관(경찰서, 소방서 등), 손해보험사, 공제조합(버스, 화물, 택시 등) 사고사실확인서
2. 산업재해 : 산업재해처리내역서 또는 보험급여지급확인서
3. 군인재해사고 : 공무상병인증서
4. 의료사고 등 법원분쟁 : 법원판결문
5. 기타 재해사고 : 공공기관(경찰서, 소방서 등) 사고사실확인서
6. 확인서류 발급불가 재해사고 : 병원초진차트 등 재해사고 증명서류 및 보험금 청구서상 재해사고내용 기재
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Ⅳ. 보험금 청구 및 지급절차 안내
구 분
구비서류
공통서류
- 보험금청구서(재물·배상)
- 피보험자의 가족관계확인서(중복보험 확인용도)
- 보험금수취인의 신분증 및 통장사본
- 합의서
의료비
입원
- 진단서(20만원 미만시 입원확인서로 대체가능)
- 진료비영수증
- 진료비 세부내역서(본인부담금 50만원 이하 또는 비급여 내역이 없는 경우 생략)
- 초진기록지, 간호정보조사지
통원
- 통원(진료)확인서 또는 병명 기재된 챠트
- 일자별 영수증 및 약국영수증(병원처방전필수)
* 카드 결제 영수증은 증빙서류가 아님
- 초진기록지
대인
치료비
- 피해자 신분증
- 진단서 또는 초진차트(진단명 명시)
- 치료비 영수증
- 입원확인서(입원시)
- 상급병실 사용 확인서(법정전염병 또는 중환자로서 특별히 인정되는 경우 지급)
- 개호소견서
- 향후 치료비 추정서(치료 현재시점 이후에 지속적 가료를 요하는 경우)
휴업손해
- 피해자 소득 입증자료(근로소득 원천징수 영수증, 최근 3개월간 임금 대장, 근로계약서 등)
후유장해
- 후유장해 진단서(맥브라이드식 장해평가)
* 발급時 보상담당자와 상의하시기 바랍니다.
사망
- 사망진단서(사체검안서)
- 가족관계증명서, 기본증명서(망자의 기본증명서 및 각 상속인의 기본증명서 포함)
- 제적등본
- 통장사본
- 법정상속인이 다수인 경우 대표자에게 위임時 각각의 위임장 및 인감증명서(또는 본인서명
사실확인서, 안전성과 신뢰성이 확보된 전자적 수단을 활용한 보험수익자 의사표시의 확인
방법 포함) 첨부
대물
- 피해자 신분증
- 파손사진
- 피해물의 등록증(차량등록증, 건물등기부등본 등)
- 수리불가 확인서(수리 불가시)
- 수리비 영수증
3. 배상책임사고
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Ⅴ. 자주 발생하는 민원 예상
01. 고지의무 관련 사례
02. 가입 초기 해약환급률 과소 관련 사례
유의사항
유의사항
⦿ A씨는 보험가입 후 계약전 알릴의무 사항에 대하여 사실과 다르게 고지한 부분을 사유로 보험금 청구시
보험금을 받지 못함에 대해 민원 제기
⦿ A씨는 보험가입 6개월 후 개인사유로 보험계약을 해지하였으며, 해지시 해약환급금이 납입한 보험료보다
적은 것에 대한 민원 제기
보험계약자 또는 피보험자는 청약시에 보험회사가 서면으로 질문한 중요한 사항에 대하여 사실대로
기재하고 자필(전자)서명을 하셔야 합니다. 만일, 고의 또는 중대한 과실로 중요한 사항에 대하여
사실과 다르게 알린 경우, 보험사는 보험계약자 또는 피보험자의 의사와 관계없이 계약을 해지하거나
보장을 제한할 수 있습니다.
※ 과거 질병 치료사실 등을 보험설계사에게 알린 경우에는 보험회사에 알리지 않은 것으로 간주되므로,
반드시 청약서에 서면으로 알리시기 바랍니다.
보험계약은 은행의 저축과 달리 납입한 보험료 중 일부는 다른 계약자에게 보험금으로 지급되며,
또다른 일부는 보험회사의 운영에 필요한 경비로 사용되어 해약환급금이 납입한 보험료보다 적거나
없을 수 있습니다.
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03. 해약환급금 과소 관련 사례
유의사항
(1종(세만기형) 2형(납입후 해약환급금지급형의 50%지급형) 가입자에 한함)
⦿ A씨는 1종 2형(납입후 해약환급금지급형의 50%지급형)을 20년동안 보험료를 납입하는 구조로 가입하고
성실하게 보험료를 납부해오다 15년 후 개인사유로 보험계약을 해지하였으나 해약환급금이 없는 것에
대한 민원 제기
1종 2형(납입후 해약환급금지급형의 50%지급형)은 납입기간 중에 해지시 해약환급금이 없는 반면
1종 1형(해약환급금 지급형) 대비 낮은 보험료로 가입하실 수 있습니다.
해약환급금 및
보험료 수준
1종 1형
(해약환급금 지급형)
>=
1종 2형
(납입후
해약환급금지급형의 50%지급형)
04. 암진단비 면책관련 사례
유의사항
⦿ A는 보험 가입 2개월 지난 시점에 위암진단 판정을 받고, 보험금을 청구하였으나, 보험금 지급이 거절되어
민원 제기
약관에 의거하여, 암(갑상선암, 제자리암, 기타피부암, 경계성종양 제외)은 계약일 이후 90일의
면책기간을 설정하고 있으며, 면책기간에 발생한 암진단(갑상선암, 제자리암, 기타피부암,
경계성종양 제외)은 보험금을 지급하지 않습니다. 90일이 경과된 이후에도 일정기간(1년) 이내인
경우 보험금이 삭감될 수 있습니다.
Ⅴ. 자주 발생하는 민원 예상
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Ⅴ. 자주 발생하는 민원 예상
05. 자동갱신 및 갱신시 보험료 인상 관련 사례
06. 질병손해 보장 관련 사례
유의사항
유의사항
⦿ A씨는 갱신형 보장에 대한 자동갱신 안내문을 받고 갱신형 보장의 보험료가 많이 인상됐다는 사실을
확인하고 민원제기
⦿ A씨는 질병보험에 가입 후 뇌졸중(I64) 진단을 받고 보험금을 청구하였으나, 보험금 지급이 거절되어
민원 제기
자동갱신 보장은 만기일의 전일까지 계약자의 별도의 의사표시가 없을 때에는 만기일의 다음날에
자동 갱신되고, 갱신시 피보험자의 연령증가 및 해당 보장의 손해율에 따라 보험료가 인상될 수 있으며,
인상폭은 계약당시에 예측한 해당 보장의 손해율 차이에 따라 달라질 수 있습니다.
뇌졸중이라 하더라도 약관에서 정의된 뇌졸중(질병분류코드 상 I60, I61, I62, I63, I65, I66에 해당하는
뇌졸중)으로 진단시에만 보험금이 지급되고 있습니다. 이 외 I64, I67, I68, I69로 진단시 보험금이
지급되지 않습니다.
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Ⅵ. 보험용어 해설
용어
설명
보험약관
보험계약에 관하여 보험계약자와 보험회사 상호간에 이행하여야 할 권리와 의무를 규정한 것
보험증권
보험계약의 성립과 그 내용을 증명하기 위하여 보험회사가 보험계약자에게 교부하는 증서
보험계약자
보험회사와 계약을 체결하고 보험료 납입의무를 지는 사람
피보험자
<신체손해/비용손해 보장>
보험사고 발생의 대상이 되는 사람
<재물손해/배상책임 보장>
보험사고가 발생함으로서 손해를 입을 수 있는 사람, 즉 피보험이익을 지니고 있는 사람을
말하며, 해당 보험금을 청구할 수 있는 사람
보험수익자
보험사고 발생시 보험금 청구권을 갖는 사람
보험료
ㆍ보장보험료 : 보험계약에 따른 보장을 받기 위하여 보험계약자가 보험회사에 납입하는 보험료
ㆍ적립보험료 : 회사가 적립한 금액을 돌려주는데 필요한 보험료
ㆍ적립부분 순보험료 : 적립보험료에서 적립부분 사업비를 공제한 후의 금액
※ 보험료 = 보장보험료 + 적립보험료
보험금
<신체손해/비용손해 보장>
피보험자의 사망, 장해, 입원 등 보험금 지급사유가 발생하였을 때 보험회사가 보험수익자에게
지급하는 금액
<재물손해/배상책임 보장>
피보험자의 배상책임손해 보험금 지급사유가 발생하였을 때 보험회사가 피보험자에게 지급
하는 금액
보험기간
보험계약에 따라 보장을 받는 기간
보장개시일
보험회사의 보험금 지급의무가 시작되는 날
보험계약일
보험계약자와 회사와의 보험계약 체결일
보험가입금액
보험금, 보험료 및 계약자적립액 등을 산정하는 기준이 되는 금액
계약자적립액
ㆍ계약자적립액 = 보장부분 계약자적립액 + 적립부분 계약자적립액
ㆍ보장부분 계약자적립액 : 장래의 보험금 지급을 위하여 보험계약자가 납입한 보장순보험료 중
일정액을 “보험료 및 해약환급금 산출방법서”에서 정하는 바에 따라
보험회사가 적립해 둔 금액
ㆍ적립부분 계약자적립액 : 장래의 만기환급금 지급을 위하여 보험계약자가 납입한 적립
순보험료를 “보험료 및 해약환급금 산출방법서”에서 정하는 바에
따라 보험회사가 적립해 둔 금액
29

Ⅵ. 보험용어 해설
해약환급금
ㆍ계약의 효력 상실 또는 해지시 보험계약자에게 돌려주는 금액으로 아래와 같음
구분
납입기간 중
납입기간 후
1종 1형(해약환급금 지급형)
2종 1형(20년갱신형)
2종 2형(30년갱신형)
계약자적립액에서 해약공제액
(미상각 신계약비)을
차감한 금액
해약환급금
1종 2형
(납입후
해약환급금지급형의 50%지급형)
없음
1종 1형
(해약환급금 지급형)
해약환급금의 50%
2종 3형
(30년갱신형)
없음
없음
ㆍ해약공제액(미상각 신계약비) : 신계약을 청약하고 승낙하는 과정에서 소요되는 비용을
계약체결비용이라 하며, 일정기간 동안 보험료에서 균등하게 공제함. 그러나 계약을 중도에
해지하게 될 경우, 공제하지 못한 계약체결비용을 한꺼번에 공제하게 되는데 이를 해약공제액
(미상각 신계약비)라 함
ㆍ해약환급금
= 보장부분 해약환급금 + 적립부분 해약환급금(1종(세만기형) 1형, 2종(갱신형) 1형, 2형에
한함)
30

- 31 -
목 차
흥국화재 약관 이용 Guide Book
시각화 된 흥국화재 약관 요약서
Ⅰ. 보험계약의 개요 ····························································································································· 8
Ⅱ. 소비자가 반드시 알아두어야 할 유의사항 ······················································································ 11
Ⅲ. 보험계약의 일반사항 ····················································································································· 16
Ⅳ. 보험금 청구 및 지급절차 안내 ······································································································ 20
Ⅴ. 자주 발생하는 민원 예상 ·············································································································· 26
Ⅵ. 보험용어 해설 ······························································································································ 29
보 통 약 관
제1관 목적 및 용어의 정의 ················································································································· 40
제1조(목적) ···································································································································· 40
제2조(용어의 정의) ························································································································· 40
제2관 보험금의 지급 ·························································································································· 42
제3조(보험금의 지급사유) ··············································································································· 42
제4조(「암」,「갑상선암」 및 「기타피부암」의 정의 및 진단 확정) ··············································· 42
제5조(보험금 지급에 관한 세부규정) ······························································································· 43
제6조(보험금을 지급하지 않는 사유) ······························································································· 44
제7조(보험금 지급사유의 통지) ······································································································· 44
제8조(보험금 등의 청구) ················································································································· 44
제9조(보험금 등의 지급절차) ·········································································································· 45
제10조(중도인출) ···························································································································· 46
제11조(공시이율의 적용 및 공시) ···································································································· 46
제12조(만기환급금의 지급) ············································································································· 47
제13조(보험금 받는 방법의 변경) ···································································································· 47
제14조(주소변경통지) ····················································································································· 48
제15조(보험수익자의 지정) ············································································································· 48
제16조(대표자의 지정) ···················································································································· 48
제3관 계약자의 계약 전 알릴 의무 등 ································································································ 49
제17조(계약 전 알릴 의무) ············································································································· 49
제18조(알릴 의무 위반의 효과) ······································································································· 49
제19조(사기에 의한 계약) ··············································································································· 50
제4관 보험계약의 성립과 유지 ············································································································ 50
제20조(보험계약의 성립) ················································································································· 50
제21조(청약의 철회) ······················································································································· 51

- 32 -
제22조(약관 교부 및 설명의무 등) ·································································································· 51
제23조(계약의 무효) ······················································································································· 53
제24조(계약내용의 변경 등) ············································································································ 53
제25조(보험나이 등) ······················································································································· 54
제26조(보통약관 계약의 소멸) ········································································································ 55
제26조의2(계약의 소멸시 계약자적립액의 청구) ·············································································· 55
제27조(계약의 자동갱신) ················································································································· 55
제5관 보험료의 납입 ·························································································································· 56
제28조(제1회 보험료 및 회사의 보장개시) ······················································································ 56
제29조(갱신계약 제1회 보험료의 납입연체와 계약의 해제) ······························································ 57
제30조(제2회 이후 보험료의 납입) ·································································································· 57
제31조(보험료 납입면제) ················································································································· 57
제32조(보험료 납입면제에 관한 세부규정) ······················································································· 58
제33조(보험료의 자동대출납입) ······································································································· 60
제34조(보험료의 납입이 연체되는 경우 납입최고(독촉)와 계약의 해지) ············································ 60
제35조(보험료의 납입을 연체하여 해지된 계약의 부활(효력회복)) ···················································· 61
제36조(강제집행 등으로 인하여 해지된 계약의 특별부활(효력회복)) ················································· 62
제6관 계약의 해지 및 해약환급금 등 ·································································································· 62
제37조(계약자의 임의해지 및 피보험자의 서면동의 철회) ································································ 62
제37조의2(위법계약의 해지) ··········································································································· 62
제38조(중대사유로 인한 해지) ········································································································ 63
제39조(회사의 파산선고와 해지) ····································································································· 63
제40조(해약환급금) ························································································································· 63
제41조(보험계약대출) ····················································································································· 64
제42조(배당금의 지급) ···················································································································· 64
제7관 분쟁의 조정 등 ························································································································· 64
제43조(분쟁의 조정) ······················································································································· 64
제44조(관할법원) ···························································································································· 65
제45조(소멸시효) ···························································································································· 65
제46조(약관의 해석) ······················································································································· 65
제47조(설명서 교부 및 보험안내자료 등의 효력) ············································································· 65
제48조(회사의 손해배상책임) ·········································································································· 65
제49조(개인정보보호) ····················································································································· 66
제50조(준거법) ······························································································································· 66
제51조(예금보험에 의한 지급보장) ·································································································· 66

- 33 -
※ 가입하신 갱신형 주기에 따라 아래 특별약관 명칭에 (갱신형_20년) 또는 (갱신형_30년)이 추가로 기
재됩니다.
※ 단, 항암양성자방사선치료비Ⅱ, 항암세기조절방사선치료비Ⅱ, 항암세기조절방사선치료비(토모테라피)
Ⅱ, 항암정위방사선치료비Ⅱ, 표적항암약물허가치료비Ⅱ, 표적항암약물허가치료비Ⅱ(연간1회한), 항
암호르몬약물허가치료비(기타피부암 및 갑상선암이외의 암)Ⅱ, 갑상선암호르몬약물허가치료비Ⅱ, 카
티(CAR-T) 항암약물허가치료비(연간1회한), 특정유방병변 진공보조장치이용절제치료비(최초1회한),
고강도초음파집속술(HIFU) 치료비(특정부인과질환)(최초1회한), 특정중등도자궁경부이형성증진단비,
특정경도이상자궁경부이형성증진단비, 다빈치및레보아이로봇 암수술비(최초1회한), 다빈치로봇 특정
수술비(연간1회한), 자궁 및 난소 특정질환 로봇수술비(연간1회한), 암 MRI검사지원비(급여_연간1회
한) 및 암 PET검사지원비(급여_연간1회한), 특정면역항암약물허가치료비(연간1회한)(갱신형_10년),
항암중입자방사선치료비 특별약관의 경우 가입하신 갱신형 주기와 상관 없이 (갱신형_10년)이 추가
로 기재됩니다.
특 별 약 관
제1장. 상해관련 특별약관 ··················································································································· 68
1. 일반상해후유장해(3~100%) 특별약관 ························································································· 68
2. 일반상해후유장해(80%이상) 특별약관 ························································································· 71
3. 일반상해사망 특별약관 ··············································································································· 74
제2장. 질병관련 특별약관 ··················································································································· 78
1. 질병후유장해(3~100%)(감액없음) 특별약관 ················································································ 78
2. 질병후유장해(80%이상)(감액없음) 특별약관 ················································································ 79
3. 암후유장해(3~100%)(감액없음) 특별약관 ···················································································· 81
4. 암사망(감액없음) 특별약관 ········································································································· 84
5. 신통합암(전이포함)진단비Ⅱ(유사암제외) 특별약관 ······································································ 86
6. 신통합암(전이포함)진단비Ⅱ(유사암제외)(면책없음,감액없음) 특별약관 ········································· 94
7. 신통합암(원발후전이포함)진단비Ⅱ(유사암제외) 특별약관 ··························································· 101
8. 신통합암(원발후전이포함)진단비Ⅱ(유사암제외)(면책없음,감액없음) 특별약관 ······························ 109
9. 암진단비(유사암제외) 특별약관 ································································································· 115
10. 암진단비(유사암제외)(면책없음,감액없음) 특별약관 ·································································· 117
11. 유사암진단비 특별약관 ··········································································································· 119
12. 유사암진단비(감액없음) 특별약관 ···························································································· 121
13. 암진단비(소액암 및 유사암제외)(감액없음) 특별약관 ······························································· 122
14. 암진단비(소액암 및 유사암제외)(면책없음,감액없음) 특별약관 ················································· 125
15. 암진단비(유방암 및 유사암제외)(면책없음,감액없음) 특별약관 ················································· 127
16. 암진단정기검진비(10년)(6개월지급형) 특별약관 ······································································· 129
17. 암진단(유사암제외)정기검진비(10년)(6개월지급형) 특별약관 ···················································· 132
18. 11대특정암진단비(감액없음) 특별약관 ····················································································· 134
19. 고액치료비암진단비(감액없음) 특별약관 ·················································································· 136
20. 갑상선암(초기제외)진단비 특별약관 ························································································· 138
21. 재진단암진단비 특별약관 ········································································································ 140
22. 재진단암Ⅲ진단비 특별약관 ····································································································· 147
23. 전이암진단비 특별약관 ··········································································································· 153

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24. 재발암 및 잔여암진단비(2년대기형)(감액없음) 특별약관 ·························································· 156
25. 항암방사선치료후 9대합병증진단비 특별약관 ··········································································· 161
26. 신통합항암방사선약물치료비Ⅱ(유사암제외) 특별약관 ······························································· 165
27. 신통합항암방사선약물치료비Ⅱ(유사암제외)(면책없음,감액없음) 특별약관 ································· 173
28. 항암방사선치료비(치료당) 특별약관 ························································································· 179
29. 중증갑상선암진단비(감액없음) 특별약관 ·················································································· 181
30. 항암방사선약물치료비 특별약관 ······························································································ 183
31. 항암방사선약물치료비(면책없음,감액없음) 특별약관 ································································· 186
32. 항암방사선약물치료비(연간1회한) 특별약관 ············································································· 188
33. 항암양성자방사선치료비Ⅱ 특별약관 ························································································ 191
34. 항암세기조절방사선치료비Ⅱ 특별약관 ····················································································· 194
35. 항암세기조절방사선치료비(토모테라피)Ⅱ 특별약관 ·································································· 197
36. 항암정위방사선치료비Ⅱ 특별약관 ··························································································· 200
37. 표적항암약물허가치료비Ⅱ 특별약관 ························································································ 204
38. 표적항암약물허가치료비Ⅱ(연간1회한) 특별약관 ······································································· 208
39. 항암호르몬약물허가치료비(기타피부암 및 갑상선암이외의 암)Ⅱ 특별약관 ································ 214
40. 갑상선암호르몬약물허가치료비Ⅱ 특별약관 ·············································································· 218
41. 카티(CAR-T) 항암약물허가치료비(연간1회한) 특별약관 ··························································· 223
42. 특정면역항암약물허가치료비(연간1회한)(갱신형_10년) 특별약관 ··············································· 228
43. 항암방사선치료비 특별약관 ····································································································· 234
44. 항암약물치료비 특별약관 ········································································································ 237
45. 말기암 호스피스 완화의료병동 입원치료비(최초1회한) 특별약관 ·············································· 240
46. 양성뇌종양진단비 특별약관 ····································································································· 243
47. 크론병 및 궤양성대장염진단비 특별약관 ················································································· 244
48. 갑상선기능항진증치료비 특별약관 ··························································································· 246
49. 특정유방병변 진공보조장치이용절제치료비(최초1회한) 특별약관 ·············································· 248
50. 고강도초음파집속술(HIFU) 치료비(특정부인과질환)(최초1회한) 특별약관 ·································· 250
51. 갑상선 바늘생검 조직병리진단비(급여_연간1회한) 특별약관 ····················································· 252
52. 유방 바늘생검 조직병리진단비(급여_연간1회한) 특별약관 ························································ 254
53. 전립선 바늘생검 조직병리진단비(급여_연간1회한) 특별약관 ····················································· 257
54. 심부 바늘생검 조직병리진단비(급여_연간1회한) 특별약관 ························································ 259
55. 자궁 생검 조직병리진단비(급여_연간1회한) 특별약관 ······························································ 261
56. 특정4대질환 헬리코박터제균치료비(최초1회한) 특별약관 ························································· 263
57. 특정갑상선기능저하증진단비(선천성 제외) 특별약관 ································································ 265
58. 특정중등도자궁경부이형성증진단비 특별약관 ··········································································· 266
59. 질병입원비(1일-180일) 특별약관 ···························································································· 269
60. 질병입원비(1일-210일) 특별약관 ···························································································· 270
61. 질병입원비(요양,정신,한방병원제외)(181일이상) 특별약관 ························································ 272
62. 질병중환자실입원비(1일-180일) 특별약관 ··············································································· 274
63. 질병수술동반입원비(1일-20일) 특별약관 ················································································· 276
64. 암수술동반입원비(상급종합병원)(1일-20일) 특별약관 ······························································ 281
65. 간병인사용 질병입원비(요양병원제외)(1일당8시간이상)(1일-180일) 특별약관 ··························· 288
66. 간병인사용 질병입원비(요양병원)(1일-180일) 특별약관 ··························································· 292
67. 간병인사용 질병입원비(요양,정신,한방병원제외)(1일당8시간이상)(181일이상) 특별약관 ············ 295
68. 간호·간병통합서비스사용 질병입원비(1일-180일) 특별약관 ······················································ 299
69. 간호·간병통합서비스사용 질병입원비(요양,정신,한방병원제외)(181일이상) 특별약관 ················· 303
70. 간병인사용 질병입원지원비(요양병원제외)(간병인비용연간200만원이상) 특별약관 ····················· 306

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71. 간병인사용 질병입원지원비(요양병원)(간병인비용연간200만원이상) 특별약관 ··························· 312
72. 간호·간병통합서비스사용 질병입원비(1일-60일) 특별약관 ························································ 318
73. 간호·간병통합서비스사용 질병입원비(종합병원)(1일-60일) 특별약관 ········································ 321
74. 간호·간병통합서비스사용 질병입원비(상급종합병원)(1일-60일) 특별약관 ·································· 325
75. 암직접치료입원비(요양병원제외)(1일-180일) 특별약관 ····························································· 328
76. 암직접치료입원비(요양병원제외)(1일-210일) 특별약관 ····························································· 332
77. 요양병원 암입원비(1일-90일) 특별약관 ··················································································· 336
78. 암직접치료 종합병원입원비(1일-180일) 특별약관 ···································································· 340
79. 암직접치료 상급종합병원입원비(1일-180일) 특별약관 ····························································· 345
80. 암(유사암포함)중환자실입원비(1일-30일) 특별약관 ·································································· 349
81. 암직접치료통원비(연간30회한)(감액없음) 특별약관 ·································································· 353
82. 암직접치료 종합병원통원비(연간30회한)(감액없음) 특별약관 ···················································· 356
83. 암직접치료 상급종합병원통원비(연간30회한)(감액없음) 특별약관 ············································· 360
84. 질병수술비 특별약관 ·············································································································· 363
85. 질병수술비Ⅱ 특별약관 ··········································································································· 366
86. 8대기관 양성신생물(용종포함)수술비(연간1회한) 특별약관 ······················································· 369
87. 특정5대암 중증수술비(급여_최초1회한)(감액없음) 특별약관 ····················································· 371
88. 암수술비(유사암제외)(최초1회한)(감액없음) 특별약관 ······························································ 376
89. 암수술비(유사암제외)(감액없음) 특별약관 ················································································ 379
90. 암수술비(유사암제외)(25%체증형)(감액없음) 특별약관 ····························································· 383
91. 유사암수술비(감액없음) 특별약관 ···························································································· 386
92. 암1~5종수술비(수술당) 특별약관 ···························································································· 388
93. 암1~5종수술비(동일질병당) 특별약관 ······················································································ 393
94. 유방수술비(유방암,유방의제자리암) 특별약관 ··········································································· 397
95. 자궁적출수술비(여성생식기암,여성생식기의제자리암) 특별약관 ················································· 401
96. 다빈치및레보아이로봇 암수술비(최초1회한) 특별약관 ······························································ 404
97. 다빈치로봇 특정수술비(연간1회한) 특별약관 ··········································································· 409
98. 자궁 및 난소 특정질환 로봇수술비(연간1회한) 특별약관 ·························································· 411
99. 암 MRI검사지원비(급여_연간1회한) 특별약관 ··········································································· 415
100. 암 PET검사지원비(급여_연간1회한) 특별약관 ········································································ 418
101. 암직접치료통원비(연간10회한)(감액없음) 특별약관 ································································ 420
102. 암직접치료 종합병원통원비(연간10회한)(감액없음) 특별약관 ·················································· 424
103. 암직접치료 상급종합병원통원비(연간10회한)(감액없음) 특별약관 ··········································· 427
104. 특정경도이상자궁경부이형성증진단비 특별약관 ······································································ 431
105. 특정NGS유전자패널검사지원비(급여_연간1회한) 특별약관 ······················································ 433
106. 중증질환자(신규암(유사암제외)) 산정특례대상보장 특별약관 ·················································· 436
107. 중증질환자(중복암 및 재등록암) 산정특례대상보장(감액없음) 특별약관 ·································· 441
108. 대장용종제거수술비(급여,용종개수당) 특별약관 ····································································· 446
109. 보험료납입지원보장(유사암진단) 특별약관 ············································································· 448
110. 중증질환자(신규암(유사암)) 산정특례대상보장 특별약관 ························································· 450
111. 암주요치료비(유사암제외)(연간1회한,진단후10년)(감액없음) 특별약관 ···································· 454
112. 암주요치료비(유사암)(연간1회한, 진단후10년)(감액없음) 특별약관 ········································· 459
113. 종합병원 1인실(특실포함) 질병입원비(1일-30일) 특별약관 ···················································· 463
114. 상급종합병원 1인실(특실포함) 질병입원비(1일-30일) 특별약관 ·············································· 466
115. 종합병원 2~3인실 질병입원비(1일-30일) 특별약관 ······························································· 468
116. 상급종합병원 2~3인실 질병입원비(1일-30일) 특별약관 ························································· 471
117. 종합병원 질병수술비 특별약관 ······························································································ 474

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118. 상급종합병원 질병수술비 특별약관 ························································································ 477
119. 전신마취암수술비(감액없음) 특별약관 ··················································································· 480
120. 신재진단암진단비Ⅱ(기타피부암,갑상선암 및 전립선암 포함, 5회한) 특별약관 ························ 485
121. 상급종합병원(국립암센터 및 원자력병원포함) 암주요치료비(유사암제외)(연간1회한,진단후10년)
(감액없음) 특별약관 ············································································································· 491
122. 상급종합병원(국립암센터 및 원자력병원포함) 암주요치료비(유사암)(연간1회한,진단후10년)
(감액없음) 특별약관 ············································································································· 496
123. 질병수술비(특정6대질병Ⅱ제외) 특별약관 ·············································································· 501
124. 상급종합병원 질병수술비(특정6대질병Ⅱ제외) 특별약관 ························································· 504
125. 질병수술비(특정8대질병제외) 특별약관 ·················································································· 507
126. 비급여 암주요치료비(전액본인부담포함,연간1회한,진단후10년)(감액없음) 특별약관 ················· 510
127. 비급여 항암약물치료비(전액본인부담포함,연간1회한,진단후10년)(감액없음) 특별약관 ·············· 515
128. 항암중입자방사선치료비 특별약관 ························································································· 520
129. 간병인사용 질병입원비(종합병원)(1일-180일) 특별약관 ························································· 523
130. 간병인사용 질병입원비(상급종합병원)(1일-180일) 특별약관 ··················································· 527
131. 암주요치료비Ⅱ(유사암제외)(치료별 연간1회한)(감액없음) 특별약관 ········································ 531
132. 암주요치료비Ⅱ(유사암)(치료별 연간1회한)(감액없음) 특별약관 ·············································· 538
133. 암주요치료비Ⅱ(유사암제외)(연간1회한,진단후10년)(감액없음) 특별약관 ································· 543
134. 암주요치료비Ⅱ(유사암)(연간1회한,진단후10년)(감액없음) 특별약관 ········································ 549
135. 상급종합병원Ⅱ 암주요치료비Ⅱ(유사암제외)(치료별 연간1회한)(감액없음) 특별약관 ··············· 554
136. 상급종합병원Ⅱ 암주요치료비Ⅱ(유사암)(치료별 연간1회한)(감액없음) 특별약관 ······················ 560
137. 상급종합병원(국립암센터 및 원자력병원포함) 암주요치료비Ⅱ(유사암제외)
(연간1회한,진단후10년)(감액없음) 특별약관 ·········································································· 565
138. 상급종합병원(국립암센터 및 원자력병원포함) 암주요치료비Ⅱ(유사암)(연간1회한,진단후10년)
(감액없음) 특별약관 ············································································································· 571
139. 비급여 암주요치료비(전액본인부담포함,연간1회한)(감액없음) 특별약관 ·································· 576
140. 암진단비(유사암제외)(5회지급형) 특별약관 ············································································ 582
제3장. 상해 및 질병관련 특별약관 ···································································································· 589
1. 보험료 납입면제대상보장(암진단(유사암제외) 및 상해·질병후유장해(80%이상)) 특별약관 ············ 589
2. 응급실내원비(응급) 특별약관 ···································································································· 592
3. 가정간호치료비(급여_연간20회한) 특별약관 ··············································································· 593
4. 상급종합병원 가정간호치료비(급여_연간20회한) 특별약관 ·························································· 595
제4장. 제도성 특별약관 ···················································································································· 596
1. 특정 신체부위ㆍ질병 보장제한부 인수 특별약관 ········································································ 596
2. 선지급서비스 특별약관 ············································································································· 600
3. 보험료 자동납입 특별약관 ········································································································ 601
4. 이륜자동차 운전중(탑승포함)상해 부담보 특별약관 ···································································· 602
5. 보장보험료 납입면제 특별약관 ·································································································· 603
6. 특별조건부(할증보험료법 / 보험금감액법) 특별약관 ·································································· 604
7. 보험금대리청구인 지정서비스 특별약관 ····················································································· 605
8. 장애인전용보험 전환 특별약관 ·································································································· 606
9. 전자서명 특별약관 ··················································································································· 609
별 표

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【별표1】장해 분류표 ························································································································· 611
【별표2】기타관계법령 ······················································································································· 631
【별표3】보험금을 지급할 때의 적립이율 계산 ···················································································· 667
【별표4】악성신생물(암) 분류표 ·········································································································· 668
【별표5】제자리신생물 분류표 ············································································································ 669
【별표6】행동양식 불명 또는 미상의 신생물 분류표 ············································································ 670
【별표7】11대특정암 분류표 ··············································································································· 671
【별표8】고액치료비암 분류표 ············································································································ 673
【별표9】갑상선의 악성신생물(암) 분류표 ··························································································· 674
【별표10-1】항암방사선치료(급여) 분류표 ·························································································· 675
【별표10-2】항암약물(급여) 분류표 ···································································································· 677
【별표11-1】카티(CAR-T) 보장 대상 암 분류표 ················································································· 678
【별표11-2】카티치료제 해당 의약품명 및 성분명 분류표 ··································································· 679
【별표12】특정면역항암제 해당 의약품명 및 성분명 분류표 ································································ 680
【별표13】전신마취 의료행위 분류표 ·································································································· 682
【별표14】특정6대질병Ⅱ 분류표 ········································································································ 683
【별표15】특정8대질병 분류표 ············································································································ 684
【별표16】크론병 및 궤양성대장염 분류표 ·························································································· 685
【별표17】갑상선기능항진증 분류표 ···································································································· 686
【별표18】특정유방질환 분류표 ·········································································································· 687
【별표19-1】특정부인과질환 분류표 ··································································································· 688
【별표19-2】고강도초음파집속술(HIFU) 분류표 ··················································································· 689
【별표20】갑상선 바늘생검 조직병리진단(급여) 분류표 ······································································· 690
【별표21】유방 바늘생검 조직병리진단(급여) 분류표 ··········································································· 691
【별표22】전립선 바늘생검 조직병리진단(급여) 분류표 ······································································· 692
【별표23】특정4대질환 분류표 ············································································································ 693
【별표24】특정갑상선기능저하증(선천성 제외) 분류표 ········································································· 694
【별표25】특정중등도이상자궁경부이형성증 분류표 ············································································· 695
【별표26-1】8대기관 양성신생물 분류표 ···························································································· 696
【별표26-2】8대기관 양성신생물(용종포함) 수술(급여) 분류표 ···························································· 697
【별표27】1~5종수술 분류표 ·············································································································· 700
【별표28-1】유방암 분류표 ················································································································ 705
【별표28-2】유방의 제자리신생물 분류표 ··························································································· 706
【별표28-3】유방암 및 유방의 제자리암으로 인한 유방수술 분류표 ···················································· 707
【별표29-1】여성생식기암 분류표 ······································································································ 708
【별표29-2】여성생식기의 제자리신생물 분류표 ················································································· 709
【별표29-3】여성생식기암 및 여성생식기의 제자리암으로 인한 자궁적출수술 분류표 ·························· 710
【별표30-1】다빈치로봇 암수술 분류표 ······························································································ 711
【별표30-2】레보아이로봇 암수술 분류표 ··························································································· 711
【별표31】다빈치로봇을 이용한 특정수술 분류표 ················································································ 712
【별표32-1】자궁 및 난소 특정질환 분류표 ························································································ 713
【별표32-2】로봇수술 분류표 ············································································································· 714
【별표33】급여촬영 분류표 ················································································································· 715
【별표34】양전자 단층촬영(PET) 검사(급여) 분류표 ············································································ 724
【별표35】응급증상 및 이에 준하는 증상 ···························································································· 725
【별표36】가정간호치료(급여) 분류표 ································································································· 726

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【별표37】상급종합병원 가정간호치료(급여) 분류표 ············································································ 727
【별표38】특정경도이상자궁경부이형성증 분류표 ················································································ 728
【별표39】특정신체부위 분류표 ·········································································································· 729
【별표40】특정질병 분류표 ················································································································· 731
【별표41】급여 특정NGS유전자패널검사 분류표 ·················································································· 732
【별표42-1】중증질환자(암) 산정특례 대상질환 분류표 ······································································· 733
【별표42-2】중증질환자(암) 산정특례대상 분류표 ··············································································· 733
【별표42-3】특정소액암 분류표 ·········································································································· 734
【별표42-4】뇌·수막의 양성신생물 분류표 ·························································································· 734
【별표43】대장용종제거수술(급여) 분류표 ··························································································· 735
【별표44-1】특정5대암 분류표 ··········································································································· 736
【별표44-2】특정5대암 중증수술(급여) 분류표 ··················································································· 737
【별표45】전이암 분류표 ···················································································································· 741
【별표46】신통합암(전이포함)Ⅱ(유사암제외) 분류표 ··········································································· 742
【별표47-1】항암방사선치료후5대합병증 분류표 ················································································· 744
【별표47-2】항암방사선치료후4대합병증 분류표 ················································································· 745
【별표48】신통합암(원발후전이포함)Ⅱ(유사암제외)(원발암) 분류표 ······················································ 746
【별표49】신통합암(원발후전이포함)Ⅱ(유사암제외)(원발후전이) 분류표 ··············································· 748
【별표50】심부 바늘생검 조직병리진단(급여) 분류표 ··········································································· 749
【별표51】자궁 생검 병리진단(급여) 분류표 ························································································ 749
특별약관 색인

보 통 약 관
※ 보통약관은 계약자가 이 보험을 가입시 기본적으로 가입을 하여야 하는 약관을 말합니다.

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제1관 목적 및 용어의 정의
제1조(목적)
이 보험계약(이하 ‘계약’이라 합니다)은 보험계약자(이하 ‘계약자’라 합니다)와 보험회사(이하 ‘회사’라 합니
다) 사이에 피보험자의 상해, 질병, 비용손해 등에 대한 위험을 보장하기 위하여 체결됩니다.
제2조(용어의 정의)
이 계약에서 사용되는 용어의 정의는 이 계약의 다른 조항에서 달리 정의되지 않는 한 다음과 같습니다.
1. 계약관계 관련 용어
용 어
정 의
계약자
회사와 계약을 체결하고 보험료를 납입할 의무를 지는 사람을 말합니다.
보험수익자
회사에 보험금(신체손해 보장 및 비용손해보장의 지급사유가 발생하는 때에 한합
니다) 및 만기환급금을 청구하여 받을 수 있는 사람을 말합니다.
보험증권
계약의 성립과 그 내용을 증명하기 위하여 회사가 계약자에게 드리는 증서를 말합
니다.
진단계약
계약을 체결하기 위하여 피보험자가 건강진단을 받아야 하는 계약을 말합니다.
피보험자
보험사고의 대상이 되는 사람을 말합니다.
2. 지급사유 관련 용어
용 어
정 의
상해
보험기간 중에 발생한 급격하고도 우연한 외래의 사고로 신체(의수, 의족, 의안,
의치 등 신체보조장구는 제외하나, 인공장기나 부분 의치 등 신체에 이식되어 그
기능을 대신할 경우는 포함합니다)에 입은 상해를 말합니다.
장해
「장해분류표」(【별표1】참조)에서 정한 기준에 따른 장해상태를 말합니다.
신체
의수, 의족, 의안, 의치등 신체보조장구는 제외하나, 인공장기나 부분 의치등 신체
에 이식되어 그 기능을 대신한 경우는 포함합니다.
중요한 사항
계약 전 알릴 의무와 관련하여 회사가 그 사실을 알았더라면 계약의 청약을 거절
하거나 보험가입금액 한도 제한, 일부 보장 제외, 보험금 삭감, 보험료 할증과 같
이 조건부로 승낙하는 등 계약 승낙에 영향을 미칠 수 있는 사항을 말합니다.
보험가입금액
보험사고 발생시 보험회사가 지급하여야 할 보험금의 기준이 되는 금액으로 보험
증권에 기재된 금액을 말합니다.
한국표준질병
･사인분류
한국인의 질병 및 사인에 대하여 의무기록자료 및 사망원인통계조사(질병이환 및
사망자료)등의 표준 통계를 세계보건기구(WHO)의 국제질병분류 ICD를 기초로 그
성질의 유사성에 따라 체계적으로 유형화한 것을 말합니다.

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3. 지급금과 이자율 관련 용어
용 어
정 의
연단위 복리
회사가 지급할 금전에 이자를 줄 때 1년마다 마지막 날에 그 이자를 원금에 더한
금액을 다음 1년의 원금으로 하는 이자 계산방법을 말합니다.
예시) 연단위 복리 계산법
* 연이율 10%로 100원을 3년동안 부리시
→ [가입시] 100원(원금)
→ [1년후] 100원(원금) + 100원 × 10%(1년이자) = 총110원
→ [2년후] 100원(원금) + 100원 × 10%(1년이자)
+ [100원(원금) + 100원 × 10%] × 10% = 총121원
평균공시이율
전체 보험회사 공시이율의 평균으로, 이 계약 체결 시점의 이율을 말합니다. 이 평
균공시이율은
금융감독원
홈페이지(www.fss.or.kr)의「업무자료/보험업무」 내
「보험상품자료」에서 확인할 수 있습니다.
해약환급금
계약이 해지되는 때에 회사가 계약자에게 돌려주는 금액을 말합니다.
4. 기간과 날짜 관련 용어
용 어
정 의
보험기간
계약에 따라 보장을 받는 기간을 말합니다.
영업일
회사가 영업점에서 정상적으로 영업하는 날을 말하며, 토요일, ‘관공서의 공휴일에
관한 규정’에 따른 공휴일, 대체공휴일 및 노동절을 제외합니다.
※ 이와 연관된 법규는 【별표2】기타관계법령을 참조하시기 바랍니다.
5. 보험료 관련 용어
용 어
정 의
보험료
계약자가 계약에 의거하여 회사에 지급하여야 하는 금액을 말하며 보장보험료와
적립보험료로 구성됩니다.
보장보험료
손해를 보장하는데 필요한 보험료(보장부분에 해당하는 회사의 사업경비를 포함합
니다)를 말합니다.
적립보험료
회사가 적립한 금액을 돌려주는데 필요한 보험료(적립부분에 해당하는 회사의 사업
경비를 포함합니다)를 말합니다.
적립부분 순보험료
적립보험료에서 적립부분에 해당하는 회사의 사업경비를 공제한 보험료를 말합
니다.

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6.「갱신형」계약의 갱신관련 용어
용 어
정 의
최초계약
‘갱신형’계약이 최초로 부가되는 경우를 말합니다.
갱신계약
‘갱신형’계약의 보험기간이 끝난 후 해당 계약이 갱신 된 경우를 말합니다.
갱신일
‘갱신형’계약이 갱신되기 직전 계약의 보험기간이 끝난 날의 다음날을 말합니다.
제2관 보험금의 지급
제3조(보험금의 지급사유)
회사는 보험증권에 기재된 피보험자에게 다음의 경우에 해당되는 사유가 발생한 때에는 보험수익자에게 약
정한 보험금을 지급합니다.
1. 암후유장해(80%이상)보험금 : 보험기간 중에 제5조(보험금 지급에 관한 세부규정) 제1항 및 제2항에
서 정한 보장개시일 이후에 제4조(「암」,「갑상선암」 및 「기타피부암」의 정의 및 진단 확정)의
「암(갑상선암, 기타피부암 포함)」으로 진단이 확정되고 그 암(갑상선암, 기타피부암 포함)으로 인
하여 신체의 일부를 잃었거나 그 기능이 영구히 상실(이하 「후유장해」라고 합니다)되어 「장해분
류표」(【별표1】참조. 이하 같습니다)에서 정한 장해지급률이 80%이상에 해당하는 후유장해상태가
되었을 때에는 최초 1회에 한하여 아래의 금액을 지급

구 분
지 급 금 액
암후유장해(80%이상)보험금
이 보장의 보험가입금액
제4조(「암」,「갑상선암」 및 「기타피부암」의 정의 및 진단 확정)
① 이 보장에서 「암」, 「갑상선암」, 「기타피부암」이라 함은 제9차 한국표준질병･사인분류에 있어서
다음에 정한 질병을 말합니다.
1.「암」이라 함은 「악성신생물(암) 분류표」(【별표4】참조)에 해당하는 질병을 말합니다.
다만, 「악성신생물(암) 분류표」(【별표4】참조)에 해당하는 질병이라 할지라도 기타피부암(C44),
갑상선암(C73) 및 이들을 원발부위(최초 발생한 부위)로 하여 불명확한, 이차성 및 상세불명 부위의
악성신생물(암)(C77~C80)에
해당하는
경우이거나
전암(前癌)상태(암으로
변하기
이전상태,
Premalignant condition or condition with malignant potential)는 「암」에서 제외합니다.
[유의사항]
한국표준질병·사인분류 지침서의 "사망 및 질병이환의 분류번호부여를 위한 선정준칙과 지침"에 따라
C77~C80(불명확한, 이차성 및 상세불명 부위의 악성신생물(암)의 경우 일차성 악성신생물(암)이 확인
되는 경우에는 원발부위(최초 발생한 부위)를 기준으로 분류합니다.
다만, 이 경우에도 이차성 및 상세불명 부위의 악성신생물(암)(C77~C80)의 진단확정 시점은 원발암 진
단확정 시점으로 변경되지 않습니다.
<원발부위(최초 발생한 부위) 기준 예시>
‧ C73(갑상선의 악성신생물)이 림프절로 전이되어 C77(림프절의 이차성 및 상세불명의 악성신생물)로
진단된 경우에도 C73(갑상선의 악성신생물)에 해당하는 질병으로 봅니다.
‧ C50(유방의 악성 신생물)이 폐로 전이되어 C78.0(폐의 이차성 악성 신생물)로 진단된 경우에도 C50
(유방의 악성 신생물)에 해당하는 질병으로 봅니다.

- 43 -
2.「갑상선암」이라 함은 「악성신생물(암) 분류표」(【별표4】참조)에서 분류번호 C73(갑상선의 악성
신생물(암))에 해당하는 질병을 말합니다.
3.「기타피부암」이라 함은 「악성신생물(암) 분류표」(【별표4】참조)에서 분류번호 C44(기타 피부의
악성신생물(암))에 해당하는 질병을 말합니다.
②「암(갑상선암, 기타피부암 포함)」이라 함은 제1항의 「암」, 「갑상선암」 및 「기타피부암」을 포함한
암을 말합니다.
③「암」, 「갑상선암」, 「기타피부암」의 진단확정은 병리 또는 진단검사의학의 전문의 자격증을 가진
자에 의하여 내려져야 하며, 이 진단은 조직(fixed tissue)검사, 미세바늘흡인검사(fine needle
aspiration) 또는 혈액(hemic system)검사에 대한 현미경소견을 기초로 하여야 합니다. 이 경우 「암」,
「갑상선암」, 「기타피부암」의 진단확정 시점은 상기 검사에 의한 결과보고 시점으로 합니다.
④ 제3항에 따른 진단이 가능하지 않을 때에는 피보험자가 「암」, 「갑상선암」, 「기타피부암」으로 진
단 또는 치료를 받고 있음을 증명할 만한 문서화된 기록 또는 증거가 있어야 합니다.
<「제3항에 따른 진단이 가능하지 않을 때」 예시>
- 피보험자가 조직검사 등 병리학적 검사를 받을 여유없이 급속한 병증 악화로 사망한 경우
- 종양의 발생부위 및 피보험자의 신체상태 등의 이유로 조직을 추출하는 경우 생명의 위험을 초래할
수 있어 병리학적 검사를 시행할 수 없는 경우
제5조(보험금 지급에 관한 세부규정)
① 제3조(보험금의 지급사유) 암후유장해(80%이상)의 보장개시일은 다음 각 호를 따릅니다.
1. 최초계약의 경우 : 보험계약일부터 그 날을 포함하여 90일이 지난 날의 다음날
(단, 갑상선암, 기타피부암에 대한 보장개시일은 보험계약일로 합니다)
2. 갱신계약의 경우 : 이 특별약관의 갱신일
< 암후유장해(80%이상)의 보장개시일 >
(단, 갑상선암, 기타피부암은 제외, 최초계약에 한함)
계약일
보장개시일
90일
20XX년 4월 10일
20XX년 7월 9일
② 제35조(보험료의 납입을 연체하여 해지된 계약의 부활(효력회복))에 따라 해지계약을 부활(효력회복)하
는 경우에는 부활(효력회복)일을 계약일로 하여 제1항 제1호에서 정한 보장개시일을 적용합니다.
③ 제3조(보험금의 지급사유) 제1호에서 장해지급률이 「암(갑상선암, 기타피부암 포함)」의 진단 확정일부
터 180일 이내에 확정되지 않는 경우에는 「암(갑상선암, 기타피부암 포함)」의 진단 확정일로부터 180
일이 되는 날의 의사진단에 기초하여 고정될 것으로 인정되는 상태를 장해지급률로 결정합니다. 다만,
「장해분류표」에 장해판정시기를 별도로 정한 경우에는 그에 따릅니다.
④ 제3항에 따라 장해지급률이 결정되었으나 그 이후 보장받을 수 있는 기간에 장해상태가 더 악화된 때에
는 그 악화된 장해상태를 기준으로 장해지급률을 결정하며, 계약의 효력이 없어진 경우에는 다음 각 호
의 기간 중에 악화된 장해상태를 기준으로 장해지급률을 결정합니다.
1. 보험기간이 10년 이상인 계약은 질병의 진단확정일부터 2년 이내
2. 보험기간이 10년 미만인 계약은 질병의 진단확정일부터 1년 이내
⑤「장해분류표」에 해당되지 않는 후유장해는 피보험자의 직업, 나이, 신분 또는 성별 등에 관계없이 신
체의 장해정도에 따라 「장해분류표」의 구분에 준하여 지급액을 결정합니다. 다만, 「장해분류표」의
‧ C16(위의 악성 신생물)이 뇌로 전이되어 C79.3(뇌 및 뇌막의 이차성 악성 신생물)로 진단된 경우에도
C16(위의 악성 신생물)에 해당하는 질병으로 봅니다.

전체 약관 보기 (PDF, 761페이지)