From the definition of an accident to the degree of disability, deadlines and contributory negligence – where insurers intervene and how you can secure your benefits.
Is your private accident insurance refusing to pay your disability benefits? Disputes almost always arise over the same issues: the definition of an accident, the degree of disability, missed deadlines, or the contribution of pre-existing conditions. Rogert & Ulbrich will review the rejection and enforce your claims against the insurer.
What private accident insurance covers – and when it pays out
Private accident insurance pays out if an accident results in a permanent disability. The most important benefit is the disability benefit, a lump-sum payment the amount of which depends on the sum insured and the degree of disability. Depending on the contract, there are also other benefits such as an accident pension, daily hospital allowance, or a death benefit.
The real dispute almost always revolves around the disability benefit. This is because the insurer has several levers to pull to refuse or reduce payment: the definition of an accident, the degree of disability, the deadlines, and the contribution of pre-existing conditions.
From his previous work on the insurance side, lawyer Dario Kovac knows which of these points insurers regularly target. Knowing the order of examination allows one to effectively counter a rejection.
Is your accident insurance company refusing to pay out? Don't accept their reasoning without question – it's often open to challenge.
The definition of an accident: Section 178 of the German Insurance Contract Act (VVG) as the first hurdle
A prerequisite for any benefit payment is an accident as defined by the insurance policy. According to Section 178 of the German Insurance Contract Act (VVG), an accident occurs when the insured person involuntarily suffers bodily injury as a result of a sudden external event. Four criteria must therefore be met: a sudden event, an external influence, involuntariness, and bodily injury.
This is precisely where insurers often come in. They frequently deny external influence, for example, if an injury resulted from one's own movement, such as lifting a load. The involuntary nature of the event or its temporal connection are also questioned. Whether an incident meets the definition of an accident often hinges on a precise description of the sequence of events.
Careful and early documentation of the accident is therefore crucial. What is recorded immediately after the event can hardly be added to later.
The insurer denies that an accident even occurred? Have the sequence of events reviewed according to the legal definition of an accident.
Disability and the dispute over the degree of disability
Disability means a permanent impairment of physical or mental capacity as a result of an accident. The amount of disability compensation depends on the degree of disability, which is often determined according to a so-called scale of compensation for bodily injuries. This scale assigns fixed percentages to the loss or functional impairment of individual body parts.
The degree of disability is the second major point of contention. Insurers commission expert reports that often assess limitations conservatively. Even a few percentage points can determine the outcome by several thousand euros. We will delve deeper into how the scale of compensation for specific injuries works and where insurers regularly reduce the degree of disability in a separate article.
A qualified, independent expert opinion is often the key to correcting an underestimated degree of disability.
Does the assessed degree of disability seem too low to you? Have the assessment reviewed before you accept the invoice.
Deadlines: why disability must be determined in a timely manner
In accident insurance, deadlines often determine the entire claim. The disability must occur within the period specified in the policy terms after the accident, be medically certified, and reported to the insurer. Many contracts stipulate a 15-month deadline for medical certification and claim submission.
This deadline is tricky because it starts running even if the consequences of an accident only become apparent much later. Insurers often cite missed deadlines as grounds for denying benefits altogether. We will discuss exactly how this deadline works and what exceptions the courts recognize in a separate article.
An important legal safeguard is in place: The insurer must inform you of these deadlines (§ 186 VVG). If they fail to provide this information or do not do so properly, they generally cannot claim that a deadline has been missed. Therefore, even a seemingly missed deadline does not always mean the end of your claim.
Is the insurer claiming a missed deadline? Check whether they properly informed you of the deadline in the first place.
Pre-existing conditions, contributory factors and causality
Even if an accident and disability are established, the insurer can reduce the benefit. This is based on the so-called contributory negligence: If pre-existing conditions or infirmities contributed to the injury or its consequences, the insurer may reduce the benefit proportionally. However, this is only permissible if the contributory negligence reaches the threshold specified in the policy terms.
Closely related to this is the dispute over causality. Particularly in cases of injuries to the intervertebral disc, shoulder, or knee, insurers frequently argue that pre-existing conditions or age-related changes are the cause, thus denying any connection to the accident. We will address what constitutes legally sound documentation of causality and how to correctly calculate contributory negligence in separate articles.
The burden of proof for contributory negligence and its extent lies with the insurer. General references to age or previous illnesses are insufficient.
Is your insurer reducing your payout due to alleged pre-existing conditions? Have your claim reviewed to ensure that the contributory negligence is properly documented and calculated.
What you should do if your accident insurance doesn't pay out
A rejection or reduction is not the end of the matter. These steps are now important:
- Securing deadlines: Pay attention to the deadlines for the medical assessment and claiming of disability and have any outstanding limitation periods checked.
- Document the accident sequenceDocument the exact sequence of events of the accident and secure witnesses, photos and initial medical findings.
- Collect documentsKeep the rejection letter, the insurance terms and conditions, and all medical reports.
- Question expert opinionsHave an expert opinion on the degree of disability that is too low reviewed, if necessary by obtaining a counter-expert opinion.
- Review cuts: Demand a comprehensible justification for each contribution.
We delve deeper into the most important issues related to each point of contention in separate articles: the 15-month period, the scale of compensation for specific injuries and the degree of disability, the dispute over causality in cases of herniated discs, shoulder and knee injuries, as well as contributory negligence. An overview of our work in insurance law can be found on our accident insurance page.
The sooner you act, the more leeway you have. Have your rejection reviewed while the deadlines are still open.
Rogert & Ulbrich – Your lawyers in insurance law
Rogert & Ulbrich represent policyholders nationwide in disputes with their private accident insurance companies. Attorney Dario Kovac, who is familiar with insurers' review and rejection strategies from his previous work on the insurers' side, serves as the contact person for insurance law. We combine this insider knowledge with the firm's consumer protection experience from major cases in banking, capital markets, and automotive law. This allows us to engage with insurers on equal footing.
We review your rejection letter and your insurance policy terms, assess the accident according to the legal definition of an accident, check the assessed degree of disability and the deadlines, and scrutinize any contributory negligence. We pursue your claims against the insurer out of court. If they maintain their rejection, we will represent you in court. We involve any existing legal expenses insurance early on and obtain the coverage confirmation for you.
Has your accident insurance company rejected or reduced your disability benefits? Get in touch and secure your claims.
