How the scale of compensation for bodily injuries works and how the insurer reduces the degree of disability based on partial function, pre-existing disability, prior damage and expert opinions.
Are you in dispute with your accident insurance company over the amount of your disability benefit after an accident? The degree of disability is crucial, and this is usually determined according to the so-called scale of benefits for specific injuries. Disputes primarily revolve around partial functional impairment, pre-existing disabilities and pre-existing conditions, and how the insurer reduces the degree of disability through expert opinions. Rogert & Ulbrich review the assessment and enforce your claim against the insurer.
What the scale of compensation for bodily injuries is and why it determines the payout
The scale of disability is a table in the accident insurance policy terms and conditions. It assigns fixed degrees of disability, expressed as a percentage, to the complete loss or total loss of function of individual body parts and sensory organs. This degree of disability directly determines the amount of your benefit.
The basic calculation is simple: The disability benefit is calculated by multiplying the sum insured by the degree of disability. With a high sum insured, every percentage point can therefore make a significant difference. This is precisely why the degree of disability is the most frequent point of contention.
From his previous work on the insurance company side, lawyer Dario Kovac knows where insurers regularly reduce the severity of injuries in their scale of compensation. Understanding this system allows one to effectively challenge an excessively low assessment.
Does your payout seem too low? Don't accept the statement without checking it, because a Benefit reduction by the insurer This can often be corrected.
How the scale of compensation for limbs works: fixed values for body parts
For total loss or complete impairment, the schedule of compensation for bodily injury provides fixed percentages. The exact values depend on your specific terms; in many contracts, they fall roughly within this range:
- arm and hand: one arm at around 70 percent, one hand at about 55 percent.
- fingerThe thumb is responsible for about 20 percent of cases, the index finger for about 10 percent, and another finger for about 5 percent.
- leg and foot: one leg at around 70 percent, one foot at about 40 percent.
- sensory organs: the visual acuity of one eye at about 50 percent, the hearing of one ear at around 30 percent.
These values apply to complete loss. In practice, however, the impairment is rarely complete. This is where partial functional impairment comes into play, and this is precisely where the real dispute begins.
You don't know the values in your contract? Have your terms and conditions reviewed, because the scale of compensation for bodily injuries may differ from the usual values.
Partial functional impairment: the calculation example
If a body part is not completely but only partially impaired, the degree of disability is calculated proportionally. It is derived by multiplying the value of the limb in the compensation schedule by the degree of functional impairment.
For example: After an accident, the function of your hand is permanently reduced by half. If the disability rating for the hand is 55 percent, this results in a degree of disability of 55 percent multiplied by 50 percent, or 27.5 percent. With an insured sum of €100,000, this corresponds to a disability benefit of €27,500, provided no progressive benefit is agreed upon.
Even a small shift can have a significant impact. If the insurer assesses the functional impairment at only 30 percent instead of 50 percent, the degree of disability drops to 16.5 percent, and the benefit in this example falls to €16,500. A difference of approximately €11,000 thus depends solely on the assessment of the functional impairment.
Is your insurer assessing your functional impairment very low? This is precisely where a review is worthwhile, often with a counter-assessment.
Where the insurer breaks down the degree of disability
When assessing the benefit, the insurer has several points of leverage to reduce the degree of disability and thus the benefit:
- Impaired functionThe most common approach is a conservatively assessed impairment of function. Expert reports regularly prepared for insurers often set the percentage low.
- Classification of the body partIf a limitation is assigned to a smaller body part, such as a finger instead of the hand, the underlying value of the limb tariff decreases.
- Pre-existing disabilityIf the affected body part was already impaired before the accident, the insurer will deduct this pre-existing disability. However, the deduction must be documented and correctly calculated.
- Participation shareIf pre-existing conditions or prior damage contributed to the claim, the insurer may further reduce the payout. However, this is subject to certain conditions and thresholds, which we will discuss in more detail in a separate article.
- Overlooked progressionIf your contract includes a progression clause, the benefit increases disproportionately in cases of high disability levels. A base degree that is set too low prevents the progression from taking effect.
The key tool in this process is the expert report. The insurer commissions an expert and accepts their assessment, particularly if it results in a low degree of disability. Such reports often assess the functional impairment conservatively, downplay individual limitations in movement, and support deductions for pre-existing disabilities and prior injuries. Therefore, a one-sided report is rarely the final word.
Each of these points is verifiable. Often, several small deductions add up to a significantly lower payout.
Is the insurer basing the reduction on pre-existing disability or a low classification? Have each individual deduction reviewed.
Injuries not covered by the scale of compensation for bodily injuries
Not every injury is covered by the scale of compensation for bodily injuries. There are no fixed percentages for body regions such as the spine, internal organs, or for psychological consequences. In these cases, the degree of disability is assessed based on the extent to which your general physical or mental capacity is permanently impaired.
This method of assessment outside the standard scale of compensation for bodily injury is particularly prone to disputes because it relies more heavily on expert opinion. Therefore, meticulous medical documentation that clearly and comprehensibly demonstrates the extent of the impairment is all the more crucial.
Does your injury affect a body part not listed in the scale of compensation for bodily injuries? Have your ability to work professionally assessed.
What you should do if the degree of disability is too low
If the assessment seems too low to you, the medical and legal aspects will be examined. These steps will help:
- Trace the billing: Have the value assigned to each limb and the level of functional impairment disclosed to you.
- Review expert opinionsCheck how the report explains the functional impairment and whether it fully captures your limitations.
- Consider a counter-reportAn independent expert opinion can correct an underestimated impairment of function.
- Question deductions: Demand a comprehensible explanation for pre-existing disability and contributory negligence.
- Meet deadlines: Pay attention to the deadlines for determining and claiming disability as well as to limitation periods.
This article is part of our series on private accident insurance. We will cover the details of deadlines and how insurers reduce payouts based on contributory negligence in separate articles. You can find an overview of our work on our website. Lawyer specializing in accident insurance.
The sooner the assessment is reviewed, the better the degree of disability can be corrected. Have your statement of claim 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. 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 invoice and the underlying expert opinion, check the applied value for the limb and the functional impairment, and question deductions for pre-existing disability and contributory negligence. During 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.
Has your accident insurance company assessed your degree of disability too low? Get in touch and secure your claims.
