What surviving relatives can do if payment after death is refused due to an allegedly concealed pre-existing condition.
If an insurer refuses to pay survivor's benefits after the death of a relative because a pre-existing condition was allegedly not disclosed when the contract was signed, this claim is subject to strict conditions and is often contestable. The burden of proof lies with the insurer, deadlines apply, and not every undisclosed illness justifies a rejection. Rogert & Ulbrich will review your case and enforce your claims.
The situation: Rejection in times of bereavement
A survivor's pension or death benefit is intended to provide financial security for relatives after the insured's death. Especially when this benefit is needed, the insurer scrutinizes the contract particularly carefully. If a pre-existing condition appears in the documents that was not disclosed at the time of purchase, the insurer will refuse payment, citing a breach of the duty to disclose.
For bereaved families, this is a double burden: in addition to grief, there is financial uncertainty. Lawyer Dario Kovac is familiar with this practice from his previous work on the insurance side. It's important to note: such a rejection is not a judgment, but rather a position of the insurer that can be reviewed.
Is the insurer refusing payment? Don't accept the reason without question, because a Insurer's refusal to pay benefits is often vulnerable to attack.
What the notification requirement at the time of contract conclusion requires
At the time of signing the contract, the insured was required to answer the health-related questions truthfully. However, this pre-contractual duty of disclosure under Section 19 of the German Insurance Contract Act (VVG) has clear limits, which also benefit surviving dependents. Disclosure was only required for information explicitly requested by the insurer in writing. A general or unclear question is to the insurer's detriment.
Furthermore, the issue of causality must be addressed. According to Section 21 Paragraph 2 of the German Insurance Contract Act (VVG), the insurer remains obligated to provide coverage if the undisclosed circumstance was neither the cause of the insured event nor the extent of the benefit. If the insured died from a cause unrelated to the undisclosed illness, the accusation is usually unfounded. Therefore, a concealed back condition does not justify a denial of coverage if the death resulted from an accident or a completely different illness.
Is the insurer citing a concealed pre-existing condition? Have it checked whether this was even asked about and whether it is related to the cause of death.
Burden of proof: the insurer is now in charge.
A key point for surviving relatives: The burden of proof for a breach of the duty to disclose information lies with the insurer. They must demonstrate and prove that the insured was asked about the matter, that the information provided was false, and that the insured was at fault. General references to an entry in the patient file are insufficient.
This evidentiary situation is often difficult for the insurer because the insured can no longer be questioned. Precisely for this reason, it is worthwhile to carefully examine whether the insurer is truly fulfilling its burden of proof or merely making assumptions. A further complication for the insurer is that it must document the exact wording of the health-related questions posed at the time.
Whether the accusation is valid is therefore often a question of... Contract interpretation and breaches of duty and the evidence, which can be thoroughly examined.
Is the insurer basing the rejection solely on a single entry in the file? Have it checked whether this is sufficient to meet their burden of proof.
Deadlines and the insurer's duty to inform
The time frame also protects surviving relatives. The insurer can only invoke a breach of the duty to disclose if several conditions are met:
- Duty to informThe insurer was required to inform the insured separately and in writing of the consequences of a breach of the duty of disclosure at the time of application (§ 19 para. 5 VVG). If this information is missing, the insured generally cannot invoke the right to rescind or terminate the contract.
- One monthThe insurer must exercise its rights within one month of becoming aware of the breach of the duty to disclose (Section 21 Paragraph 1 of the German Insurance Contract Act).
- Exclusion periodsAfter five years, the insurer's rights are generally excluded; in cases of intentional or fraudulent breach, after ten years (§ 21 para. 3 VVG). For contracts dating back a long time, this is often the decisive factor.
These deadlines are frequently ignored in rejection letters. If the contract was concluded a long time ago or if the deadline is omitted, the refusal is often invalid.
Has the contract been in place for many years? Have it checked to see if the insurer's rights have long since been forfeited.
Withdrawal or fraudulent misrepresentation: the difference
The insurer can pursue two different courses of action, each with different consequences. In the case of rescission due to simple or gross negligence in the disclosure obligation, the rules of causality and time limits apply, protecting surviving dependents. If the undisclosed illness proves irrelevant to the death, the insurer often remains obligated to pay benefits.
A more stringent approach is the rescission of a contract based on fraudulent misrepresentation under Section 22 of the German Insurance Contract Act (VVG) in conjunction with Section 123 of the German Civil Code (BGB). This requires proof that the insured deliberately deceived the insurer to influence its decision. If this can be proven, the contract is considered void from the outset, and the threshold of causality does not apply. Insurers frequently raise this accusation, even though it is difficult to prove. The burden of proof for fraudulent misrepresentation rests entirely with the insurer, and mere suspicions are insufficient, especially since the insured can no longer respond.
The insurer is accusing the deceased of fraud? They must prove this serious accusation; let them refute their reasoning.
What bereaved relatives should do now
If payment is refused, a structured approach is essential. These steps will help:
- Collect documents: Compile the insurance policy, the terms and conditions, the rejection letter and, if available, the original application.
- Clarify the reason for the rejectionHave it determined whether the insurer is basing its claim on rescission or fraud, and on what exactly the accusation is based.
- Check causalityClarify whether the alleged illness is actually related to the cause of death.
- Check deadlines and noticesHave it checked whether the insurer has issued the notification pursuant to Section 19 Paragraph 5 of the German Insurance Contract Act (VVG) and has complied with the deadlines.
- Don't sign anything hastily.Do not make any statement to the insurer until the legal situation has been clarified.
We will discuss the details of the pre-contractual disclosure obligation and the points of contention surrounding payment in separate articles. Regarding the Examination and enforcement of claims arising from insurance contracts We support you. You can find an overview of our work in the section... Insurance law.
The sooner the rejection is reviewed, the better the chances of securing the benefit. Have your case assessed while the deadlines are still open.
Rogert & Ulbrich – Your lawyers in insurance law
Rogert & Ulbrich represent bereaved families nationwide when insurers refuse to pay survivor's pensions or death benefits. 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. 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 the rejection letter and the contract, clarify whether the insurer is meeting its burden of proof, and check causality, deadlines, and notification obligations. In the case of the Examination and enforcement of claims arising from insurance contracts We represent you out of court and, if necessary, in court. We involve any existing legal expenses insurance early on and obtain the coverage confirmation for you.
Is your insurer refusing to pay your survivor's pension due to an alleged breach of your duty to disclose information? Get in touch and secure your rights.
