Why the accident insurance company argues that these injuries are due to pre-existing conditions and how you can prove the connection to the accident.
Is your accident insurance refusing to pay out because a herniated disc, shoulder, or knee injury is allegedly due to pre-existing conditions or wear and tear? Insurers frequently dispute the connection to the accident in precisely these types of injuries. Crucially, the correct proof of causality and complete documentation are essential. Rogert & Ulbrich will review the denial and enforce your claims against the insurer.
Why the insurer argues with pre-existing damage in cases of herniated disc, shoulder and knee
Intervertebral discs, shoulders, and knees are body parts that are subject to natural wear and tear over the course of a lifetime. Insurers exploit this fact. They attribute injuries not to accidents, but to age-related or degenerative changes, and reject disability benefits. Disputes over causality are therefore among the most frequent reasons for a claim. Rejection of benefits by the insurer.
From his previous work on the insurance company side, lawyer Dario Kovac is familiar with these patterns of argumentation. Often, an expert opinion describing degenerative changes is sufficient for the insurer to downplay the accident as the cause. Whether this argument holds water depends on the medical findings and the documentation of the accident.
Anyone who can establish a clear and early connection to the accident undermines this strategy. Therefore, every finding and every timely examination is crucial.
Is the insurer citing pre-existing damage or wear and tear? Have the findings checked to see if they actually support this claim before you accept the rejection.
Exclusion of disc herniation and the predominant cause
Many accident insurance policies contain a special clause regarding herniated discs. According to this clause, damage to the intervertebral discs is generally excluded from coverage. Coverage only applies if an accident is the predominant cause of the damage.
This regulation is strict. It works differently than a simple deduction: If the accident is not the predominant cause, the benefit for the herniated disc is completely forfeited. It is therefore not enough that the accident made some contribution. It must be the decisive cause, which becomes the central point of contention, especially in cases of pre-existing conditions.
Whether and how this clause is worded in your contract depends solely on your insurance terms and conditions. The wording determines the requirements the proof must meet.
Is the insurer citing the exclusion for herniated discs? Have it checked whether the accident was not in fact the predominant cause.
Causality in shoulder and knee: trauma or degeneration?
Shoulder and knee injuries usually don't have a specific exclusion clause like those for herniated discs. The debate here revolves around whether the injury was caused by the accident or whether pre-existing wear and tear is the determining factor. Typical examples include rotator cuff tears in the shoulder or meniscus and cruciate ligament damage in the knee.
Two points are crucial for proving a traumatic injury. First, the mechanism of the accident: the event must have been capable of causing the specific injury. Second, the imaging findings: fresh signs of injury, such as hemorrhages or associated bone fractures, suggest a traumatic injury, while purely degenerative findings tend to argue against an accident.
A careful distinction between traumatic and degenerative findings is therefore at the heart of every discussion. It often determines the entire claim.
Does your insurer consider your shoulder or knee injury to be purely due to wear and tear? Have the accident mechanism and findings professionally assessed.
Participation or exclusion – two different mechanisms
Pre-existing damage can manifest itself in two very different ways, which are often confused:
- Exclusion with root cause analysisIn cases of herniated discs, coverage is often completely excluded, only being waived if the accident is the predominant cause. It's an all-or-nothing decision.
- Participation shareIn the case of other injuries, the insurer may reduce the benefit proportionally if pre-existing conditions played a role. This is not a complete rejection, but a percentage reduction, which is only permissible above a certain threshold.
This distinction is important because insurers sometimes conflate these two mechanisms, treating a reduction like an exclusion or vice versa. We will discuss how the contributory negligence is calculated in detail and where typical misapplications occur in a separate article.
Is your insurer reducing or rejecting your claim due to pre-existing conditions? Have it checked which mechanism is applicable and whether it was applied correctly.
How to document the accident in a way that establishes causality
The connection to the accident can best be established immediately after the event. These points are crucial:
- Go to the doctor immediatelyConsult a doctor promptly and have your symptoms documented. A delayed initial consultation weakens the connection between the symptoms and the cause.
- Document the accident sequenceDescribe the exact sequence of events and the mechanism so that it becomes clear that the event could have caused the injury.
- Initiate imagingEnsure that any fresh signs of injury are promptly detected using appropriate imaging techniques.
- Clarify backgroundNote whether and what symptoms existed previously in the affected area. A lack of pre-existing symptoms supports the connection to the accident.
- Collect all findings completelyKeep all medical reports, recordings, and diagnoses organized.
The more complete this documentation is, the harder it is for the insurer to deny the accident as the cause.
Are you unsure whether your documents prove the connection to the accident? Have them reviewed while it's still possible to add further findings.
What you should do if the insurer claims prior damage
In cases of rejection due to alleged pre-existing conditions, the medical and legal assessment is crucial:
- Rejection and expert opinion reviewHave it determined what the insurer bases its claim of prior damage on and whether the expert opinion is valid.
- Check conditionsClarify whether an exclusion clause or a contribution requirement is applied and whether the conditions are met.
- Consider a counter-reportA qualified, independent expert opinion can differentiate between traumatic and degenerative findings and refute a one-sided insurance company report.
- Meet deadlines: Pay attention to the deadlines for determining and claiming disability as well as to any applicable limitation periods.
This article is part of our overview of points of contention in private accident insurance. We will delve deeper into how disability benefits work overall and where insurers reduce payments based on contributory negligence in separate articles. You can find an overview of our work on our page for Lawyer specializing in accident insurance.
The sooner causality is examined, the better the connection to the accident can be established. Have your rejection reviewed while the deadlines are still open.
Rogert & Ulbrich – Your lawyers in insurance law
Rogert & Ulbrich represent insured parties nationwide in disputes with their private accident insurance companies. As contact persons in Insurance law Attorney Dario Kovac, who is familiar with insurers' review and rejection strategies from his previous work on the insurers' side, is on board. 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 the underlying expert report, assess the findings from a medical and legal perspective, and determine whether the insurer is justified in denying the connection to the accident. Where necessary, we commission an independent counter-report. We pursue your claims out of court; if the insurer maintains its 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 claim due to alleged pre-existing conditions? Get in touch and secure your rights.
