Dread disease insurance – what happens when the insurance company doesn't pay out in the case of serious illnesses?
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When the dread disease insurance refuses to pay out
Dread disease insurance – also known as critical illness insurance – provides financial protection in the event of a diagnosis of certain serious illnesses. Unlike... Disability insurance In the case of classic occupational disability, no monthly occupational disability pension is paid, but rather a regular one-off capital payment.
This lump sum payment is intended to enable those affected to meet financial obligations, finance treatments, or cushion income losses. It is therefore all the more distressing when the insurer rejects the claim under the dread disease insurance policy.
Rogert & Ulbrich, as lawyers specializing in insurance law, represent policyholders nationwide against their insurers. Our firm carefully reviews claims denials, contract clauses, and medical assessments, and consistently pursues legitimate claims.
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3What is dread disease insurance?
Dread disease insurance is a private insurance policy that pays out a fixed sum insured upon diagnosis of certain contractually defined serious illnesses. Typically covered illnesses include cancer, heart attack, stroke, multiple sclerosis, or certain diseases of the nervous system.
Unlike occupational disability insurance, it is irrelevant whether an occupational disability has occurred or whether the insured person is still able to work. The sole determining factor is whether one of the illnesses listed in the policy terms and conditions is present with the severity defined therein.
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Which serious illnesses are covered by insurance?
Which illnesses are covered is determined solely by the policy terms and conditions. The list is generally exhaustive. In addition to oncological diseases, coverage may also include organ transplants, coma, loss of sight or hearing, or severe head injuries.
Mental illnesses are often excluded. Likewise, many policies contain exclusions for pre-existing conditions or certain genetic predispositions.
What matters is not only the diagnosis, but also the contractually defined severity. For example, an early cancer diagnosis in its initial stages may not yet trigger a claim. Similarly, in the case of a stroke, the decisive factor is often the long-term neurological consequences.
A lawyer specializing in insurance law checks whether the insurer's interpretation of the terms and conditions is correct.
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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Difference to disability insurance
Many policyholders confuse dread disease insurance with disability insurance. While disability insurance pays a monthly occupational disability pension in the event of occupational disability, dread disease insurance provides benefits regardless of one's professional situation.
Disability is not a prerequisite for receiving benefits from a dread disease insurance policy. Conversely, a diagnosis of a serious illness does not automatically lead to disability.
Our lawyers will advise you comprehensively on the differences between occupational disability insurance, incapacity for work insurance and dread disease insurance.
Eligibility requirements and medical documentation
For dread disease insurance to pay out, the insured illness must be present in the form required by the contract. The general terms and conditions of insurance define in detail which symptoms, findings, or permanent impairments are necessary.
The policyholder generally bears the burden of proof. They must demonstrate, through medical records and findings, that the requirements are met. In practice, unclear or incomplete documentation often leads to delays or rejections by the insurer.
An insurance lawyer critically evaluates medical documents and ensures a structured presentation to the insurance company.
Waiting periods and exclusions in dread disease insurance
Many critical illness insurance policies include waiting periods or qualifying periods. Coverage only begins after a certain period has elapsed. Furthermore, certain illnesses or conditions are explicitly excluded.
Whether an exclusion was effectively agreed upon or whether the insurer is wrongly invoking it is frequently the subject of legal disputes.
Our law firm examines the effectiveness of clauses in light of insurance law and the control of general terms and conditions.
Contestation and withdrawal due to pre-contractual disclosure obligations
As with other private insurance policies, the insurer can also invoke a breach of the pre-contractual duty of disclosure in the case of dread disease insurance. If health-related questions in the application were answered incompletely or incorrectly, the insurer risks contesting or rescinding the contract.
The legal consequences can be serious: In the worst case, the policyholder loses their insurance coverage completely.
An experienced lawyer will examine whether there has actually been a relevant breach of duty or whether the insurance company must continue to pay out.
Practical examples from dread disease insurance
In one case, the insurer refused to pay out the insurance sum due to a cancer diagnosis, claiming the stage of the disease did not meet the contractual severity criteria. After medical and legal review, it was proven that the conditions were met. The insurance company paid the agreed sum.
In another case, the insurer cited an alleged pre-existing condition and declared the contract void. Upon review of the application documents, it turned out that the health questions were worded ambiguously. The withdrawal was therefore invalid.
10 Questions & Answers about Dread Disease Insurance
Have your benefit denial legally reviewed now.
If your dread disease insurance refuses to pay out the lump sum or cites exclusions, you should have the decision legally reviewed.
Have your case reviewed by an insurance lawyer. Schedule a consultation with our firm and clarify what claims you are entitled to under your insurance policy.
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