Insurance

Inability to work: Incorrect information costs insurance coverage

Summary

Be on the safe side with occupational disability insurance: If you want that, you should carefully examine your policy before signing a contract. Because application and conditions contain many pitfalls. In the event of damage, there is therefore often a […]

Inability to work: Incorrect information costs insurance coverage.  The information about a disability insurance should definitely be correct (Source: Thinkstock by Getty-Images)

Be on the safe side with occupational disability insurance: If you want that, you should carefully examine your policy before signing a contract. Because application and conditions contain many pitfalls. In the event of damage, there is therefore often a dispute with the insurer. The courts usually have the final say on whether they have to pay or not. What you should definitely pay attention to.

“Have you been examined, counseled or treated in a hospital, clinic, rehabilitation or spa facility in the past ten years?” on the lungs or the stomach? ” – Questions like these can easily put applicants for disability insurance into skid.

Answer health questions correctly

“When it comes to health issues, you have to be extremely careful that you fill them out correctly,” says Elke Weidenbach from the North Rhine-Westphalia consumer center. If you are not sure, it is better to ask your doctor. “You definitely have to get your backing.” Because the insurers do not check the accuracy of the information at the beginning of the contract, but only in the event of damage – and then reject payments.

“There is often a dispute about whether the pre-contractual notification obligation has been violated,” says Arno Schubach, specialist lawyer for insurance law from Koblenz. Back pain in particular is often not mentioned in the health questions because it is viewed as unimportant. But if you have back pain from time to time and have already received soothing injections from the doctor, you should inform your insurer of this.

Court overturned payment entitlements

Some insured people try to talk their way out of the fact that they could not have remembered or that it was not clear to them that this pre-existing condition was important. But the Karlsruhe Higher Regional Court recently made it clear once again: Anyone who objectively answers the health questions incorrectly is not entitled to payments from the occupational disability insurance (Az .: 12 U 140/12).

Even if you have the application form filled out by an intermediary, you are not protected from errors. However, in such a case the insurance company must prove that the applicant has fraudulently deceived and withheld information. It is not enough to simply claim that the insured person did not verbally sufficiently inform the mediator, decided the Karlsruhe Higher Regional Court (Az .: 12 U 20/09).

Dispute over the reorganization of companies

“In the case of the self-employed, there is also often a dispute about the obligation to reorganize the company,” says Schubach, who is also a member of the executive committee of the insurance law working group in the German Lawyers’ Association.

An example of this: a plumber who employs 20 journeymen becomes incapacitated. He can no longer do manual work himself, but in the eyes of the insurance company he could, for example, process the invoices on the computer. But a craftsman over 50 often simply does not have sufficient computer skills, says Schubach.

Judgment on the onset of occupational disability

The Bremen Higher Regional Court, however, had to deal with the relevant point in time for the occurrence of the occupational disability (Az .: 3 U 60/09). In retrospect, occupational disability occurs when, in the opinion of a doctor, no improvement in the workforce can be expected. The time of the onset of the original illness or incapacity for work are unimportant for this question.

For trainees, a decision by the Federal Court of Justice (Az .: IV ZR 119/09) is also important. If a trainee wants to take out insurance, the insurer must expand the term to include activities after completing their training. “Because as an apprentice you have a completely different working day than after your apprenticeship,” explains Schubach.

Federal Court of Justice strengthens ex-trainees

The specific case concerned a woman who had taken out disability insurance as a secretary apprentice. During her training, she suffered several cerebral haemorrhages, but was able to complete the training and then work, albeit in a different profession. The insurance company had invoked the changed activity of the woman and wanted to stop the payments. The Federal Court of Justice did not accept this argument.