Sickness benefit insurance – if the insurer refuses to pay sickness benefit
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When sick pay fails to materialize
Daily sickness allowance insurance provides financial security in the event of prolonged incapacity for work. If income is lost due to illness, the agreed daily sickness allowance is intended to compensate for the loss of earnings. For those with private health insurance and the self-employed, this coverage is often essential.
It is all the more serious if the insurer stops payments, questions the incapacity for work, or invokes termination of the contract. In such cases, the policyholder's financial stability is often at stake.
Rogert & Ulbrich, as lawyers specializing in insurance law, represent policyholders nationwide in disputes with their daily sickness allowance insurance. Our firm reviews Benefit rejections, Contract clauses and medical assessments, and consistently enforces legitimate claims.
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3When does the daily sickness allowance insurance pay out?
A prerequisite for receiving benefits from daily sickness allowance insurance is incapacity for work due to illness. For employees, continued payment of wages by the employer regularly ends after six weeks. From the contractually agreed date – often from the 43rd day – the insurer pays the agreed daily sickness allowance.
Daily sickness allowance insurance is generally a fixed-sum policy. This means that in the event of illness, the agreed daily rate is paid, regardless of the actual amount of the loss. However, the amount may not exceed the average net income.
Whether the requirements are met depends on the specific insurance terms and the doctor's assessment of incapacity for work. Disputes often arise precisely at this point.
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The insured event: total incapacity for work
According to Section 192 Paragraph 5 of the German Insurance Contract Act (VVG), entitlement to daily sickness benefits requires total incapacity for work due to illness or accident. The decisive factor is the last specific professional activity performed.
Incapacity for work exists when the insured is temporarily unable to perform their professional duties in any way, according to a medical assessment. An objective medical standard is decisive.
The insurer cannot simply claim that working from home or through reorganization would have been possible. Sickness benefit insurance is specifically designed to cover temporary loss of earning capacity.
If the insurer disputes the incapacity for work, the decision should be reviewed by a lawyer specializing in insurance law.
If your insurance company is causing problems – talk to lawyer Dario Kovac
Is your insurance company refusing to pay or delaying the settlement? Lawyer Dario Kovac He has been assisting clients with disputes with insurance companies, particularly legal expenses insurers, since 2019. His previous work at ARAG He is familiar with typical rejection strategies from practice.
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Termination of daily sickness allowance insurance in case of occupational disability
Many insurance policies stipulate that the daily sickness allowance insurance ends when Occupational disability This occurs. The background is that incapacity for work and occupational disability are different insurance cases.
If the policyholder receives an occupational disability pension, the insurer can terminate the daily sickness allowance insurance and, under certain circumstances, reclaim any daily sickness allowance already paid. However, whether this termination is effective depends on the specific terms of the contract and the date on which the occupational disability began.
An insurance lawyer checks whether the conditions for terminating the contract are actually met.
Repayment of sickness benefit
In practice, insurers sometimes demand repayment of sickness benefits already paid. This is done, for example, on the grounds that there was no incapacity for work as defined in the policy or that the insured's eligibility for insurance had ceased.
However, a claim for reimbursement is not permissible in every case. If the insurer has made payments unconditionally over a longer period, a legitimate expectation may have arisen. Whether a repayment is owed requires careful legal review.
Loss of insurability
The insurer can argue that the insurability has ceased, for example in the event of occupational disability, receipt of an old-age pension or permanent abandonment of professional activity.
Legal questions can also arise in cases of unemployment or career change. The decisive factor is whether the policyholder continues to pursue insurable employment or is making a serious effort to find new work.
In case of dispute, the insurer bears the burden of proof for the loss of insurability. However, the policyholder must provide substantiated evidence that the conditions for insurability still exist.
Waiting period in daily sickness allowance insurance
Many insurance policies include a waiting period. This refers to the time between the onset of incapacity for work and the start of sick pay payments.
Disputes often arise when there are interruptions in sick leave. The crucial question is whether there is a single, continuous insured event or whether a new one begins. Depending on the specific terms of the policy, the waiting period may apply only once or multiple times.
Here too, the interpretation of the insurance terms and conditions by a lawyer specializing in insurance law is important.
Practical examples from daily sickness allowance insurance
In one case, the insurer stopped paying sick pay on the grounds that the policyholder could partially resume work. Following a medical assessment and legal arguments, it was proven that the policyholder remained completely unable to work. Payments were resumed.
In another case, the insurer demanded repayment of already paid sickness benefits, claiming that the insured had become disabled. A legal review revealed that the conditions for terminating the contract were not met. The claim for repayment was successfully defended.
These examples show how important it can be to involve a lawyer early in insurance law matters.
10 Questions & Answers about Sickness Benefit Insurance
Have your benefit denial legally reviewed now.
If your insurer refuses to pay sickness benefits, suspends payments, or demands repayments, you should not accept the decision without question.
Have your case reviewed by an insurance law attorney to clarify what claims you are entitled to under your daily sickness allowance insurance. Schedule an initial consultation with our law firm.
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