Why causality is the primary factor and not every pre-existing condition justifies a reduction.
Is your accident insurance reducing your disability benefits due to pre-existing conditions? The so-called contributory negligence clause only allows for a reduction under strict conditions. First, it must be established that the accident was indeed the cause of your disability. Only then does the question arise as to whether an illness or infirmity actually contributed to it. Rogert & Ulbrich will review the reduction and enforce your claims.
What the co-payment is and why it reduces benefits.
The contributory negligence clause is a provision in the accident insurance terms and conditions. If illnesses or disabilities contributed to the injury caused by the accident or its consequences, the insurer may reduce the benefit proportionally. Unlike an exclusion, the benefit is not completely eliminated, but only reduced by the proportion attributable to the pre-existing condition.
For insurers, this is an effective tool, especially since many people have pre-existing conditions or signs of wear and tear. Lawyer Dario Kovac knows from his previous work on the insurance side that the contributory negligence factor is often interpreted too broadly in practice. This is precisely where a thorough examination is worthwhile.
Is your accident insurance reducing your payout due to pre-existing conditions? Don't accept the explanation without question, because a Benefit reduction by the insurer is subject to clear conditions.
First causality, then participation: the correct order
The most common mistake in practice is conflating causality and contributory negligence. These are actually two separate steps that must be carried out sequentially.
- First step: CausalityFirst, it must be established that the accident is indeed the cause of your disability. If the permanent impairment is not actually due to the accident, then it is a question of causality and insurance coverage, not of contributory negligence.
- Second step: ParticipationOnly once the accident has been established as the cause does the further question arise as to whether an illness or disability contributed to the injury or its consequences and therefore a partial reduction is possible.
This order is crucial. The insurer must not use the second step to circumvent a causal link that is actually lacking, and conversely, it must not automatically infer contributory negligence from an affirmed causal link. Both are independent issues with their own prerequisites and burden of proof.
Is the insurer conflating causality and contributory negligence? Have it examined which question is actually relevant in your case.
The participation threshold: below this level, no reduction will be made.
Even if an illness or disability has contributed to the claim, not every contribution is relevant. The terms and conditions typically stipulate a threshold for such a contribution. Only when the pre-existing condition reaches this threshold can a reduction be made.
The threshold depends on your contract. Thresholds of 25 percent are common, and in some cases, 50 percent. If the degree of contributory negligence is below this threshold, the benefit remains in full. Therefore, reviewing your specific insurance policy terms is the first step, as any reduction is inadmissible if the threshold is not reached.
Is your insurer reducing your payout despite your limited cooperation? Check whether you've even reached the threshold stipulated in your contract.
Illness or disability – not every pre-existing condition counts.
A reduction in benefits is only permissible if an illness or disability has contributed to the reduction. A disability is a permanent state of health that deviates from the norm. Not every pre-existing condition or age-related change meets this requirement.
This is a crucial point. Insurers tend to infer contributory negligence from any previous complaint or normal age-related wear and tear. However, the decisive factor is not whether pre-existing conditions were present at all, but whether a specific illness or infirmity actually contributed to the disability caused by the accident, and to what extent. Age-related wear and tear that would never have had an effect without the accident does not, in itself, justify a reduction in benefits.
Is the insurer citing your age or previous health conditions as a general reason for the claim? Have it checked whether a pre-existing condition actually contributed to the claim.
Burden of proof and typical errors of the insurer
Contributory negligence is a defense that reduces benefits. The burden of proof that an illness or disability contributed to the claim, and to what extent, therefore lies with the insurer. General references to age or previous treatments are insufficient.
In practice, several typical misuses occur:
- Confusion with causalityThe insurer treats a lack of causation as contributory negligence, or vice versa.
- Automatic deduction: A contributory negligence percentage is inferred from any pre-existing damage or wear and tear without any specific examination.
- Excessive percentageThe percentage is set too high in order to reduce benefits more significantly.
- Threshold crossedThe payment is being reduced even though the agreed participation threshold has not been reached.
Each of these points can be verified, often with the help of an independent expert opinion that clearly separates the actual contribution of the pre-existing condition from the consequences of the accident.
Is the insurer attributing a high percentage of contributory negligence to the insured? Have the percentage assessed reviewed by an expert.
What you should do if the insurer reduces your payout
In cases of benefit reductions due to pre-existing conditions, the medical and legal aspects need to be thoroughly investigated. These steps can help:
- First, clarify causality.Determine whether the accident is actually the cause of the disability or whether it is solely a question of contributory negligence.
- Check conditionsClarify what cooperation threshold your contract stipulates and whether it has been reached.
- Demand justification: Demand a comprehensible explanation of which specific illness or disability is alleged to have contributed to the problem.
- Question expert opinionsHave the insurer's report reviewed to ensure it accurately assesses the degree of contributory negligence, and consider obtaining a counter-report.
- 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 delve deeper into the specifics of the causality dispute in cases involving herniated discs, shoulders, and knees in a separate article. You can find an overview of our work on our website. Lawyer specializing in accident insurance.
The sooner the reduction is reviewed, the better your claim can be secured. Have your statement of account assessed 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' auditing and reduction 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 rejection or reduction letter and the underlying expert opinion, separate the question of causality from the question of contributory negligence, and check the threshold and amount of the assessed share. In 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 reduced your payout due to pre-existing conditions? Get in touch and secure your claims.
