Dispute over the insurer’s obligation to pay in disability insurance
Disability insurance is intended to provide important financial protection in the event that the policyholder can no longer carry out their last occupation due to health reasons. Many people take out a disability insurance policy to secure themselves and their financial future. Those affected are often urgently dependent on the payout in the event of a claim and frequently require legal assistance if the insurance company refuses to pay out, in order to secure their money. A refusal of benefits by the insurance companies often means significant financial losses and the loss of money for those concerned.
According to § 172 of the Insurance Contract Act (VVG), occupational disability exists when the person concerned can no longer carry out their last job, in whole or in part, on a permanent basis due to illness, bodily injury, or loss of strength, explains MTR Legal Rechtsanwalt , which also advises on insurance law. Insurance companies have a lot of experience in reviewing claims and often reject applications – in such cases, it is advisable to consult a specialized lawyer to enforce your claims in court if necessary. Whether the disability insurer is required to pay is often a frequent point of contention between the parties.
Entitlement to benefits from disability insurance
The basis for the insurer’s obligation to pay in disability insurance is the insurance contract. This determines under which conditions the insurance must pay. The premiums, especially the premium regularly paid by the policyholder, are decisive for financial security in the event of a claim. Despite regular premium payments and compliance with insurance conditions, there is no guarantee that the disability pension will be paid in the event of a claim. Often, it is stipulated in the insurance contract that the policyholder must be at least 50 percent disabled. That means they can only perform half or less of their last occupation. It does not matter whether the cause is a physical, psychological, or mental illness.
Another provision is the so-called “six-month prognosis,” which is included in many contracts. It states that the disability is expected to last for at least six months. So, for example, if someone is off work for two months due to burnout, they generally have no claim to benefits from disability insurance. The payment of the disability pension is tied to the fulfillment of certain conditions; if these are not met, the insurer may refuse to pay the disability pension. If, in the opinion of a doctor, the health condition is unlikely to improve in the coming months, there is usually an occupational disability, meaning the insurer must pay.
What matters is not whether the insured could theoretically perform another job. Rather, the decisive factor is whether they can still perform the job they last actually carried out. The insurer may only refer the policyholder to another occupation if the contract allows for such so-called abstract reference.
Application for disability pension
The policyholder must provide proof of their disability. This usually requires the most precise description possible of the job profile and tasks performed. The existing health impairments should be substantiated by a medical certificate or, if necessary, an expert opinion. Additional medical documents such as hospital reports or proof of therapy may also be helpful. As a general rule: The better the documents document the limitations in everyday work, the higher the probability that the insurer will recognize the claim. The claim application should be filled out with particular care, and all relevant questionnaires from the insurer should be answered completely and correctly to avoid misunderstandings or later issues.
The documents must be submitted promptly. For every question the insurer asks in the claim application, it is important to answer completely and truthfully, as mistakes in answering can result in the application being denied. Incorrect information can cause delays or rejection of the application.
Insurer refuses to pay
It happens repeatedly that the disability insurer refuses to pay benefits. One of the most common reasons for this is the lack of adequate medical evidence. The insurer usually checks itself or through external experts whether the alleged disability actually exists. As part of the benefit review, the reasons for and causes of rejection are thoroughly assessed. Experts such as specialized lawyers or insurance advisors can support those affected in understanding the reasons for the rejection and asserting their claims against the insurance company. If the insurer’s doctors reach a different conclusion than the policyholder’s treating physicians, this can lead to conflicts. Another reason for rejection, especially in older contracts, can be abstract reference. This means the insurer deems another activity reasonable. However, in newer contracts, this is usually excluded.
Another frequent point of dispute is the violation of the pre-contractual duty of disclosure by the policyholder. Anyone who conceals or provides false information about significant health details when taking out disability insurance risks having the contract contested by the insurer or the insurer exercising its right of withdrawal. In such cases, the obligation to pay can lapse retroactively, even if the current disability is unrelated to the concealed pre-existing condition. Another reason for rejection can be a lack of cooperation from the insured person. For example, if no medical documents are submitted, medical examinations are refused, or job activities are insufficiently described. In such situations, policyholders should heed expert advice and explore the various options available for challenging a denial in order to successfully assert their claims to a disability pension or payout.
The importance of the pre-contractual duty of disclosure
The pre-contractual duty of disclosure plays a central role in disability insurance and is crucial to insurance coverage. When taking out disability insurance, the policyholder is obliged to provide the insurer with all relevant information about their state of health and possible risks fully and truthfully. In particular, the health questions asked as part of the application should be answered with the utmost care, as they form the basis for the insurer’s risk assessment and subsequent obligation to pay benefits.
Mistakes or omissions in answering these health questions can cause significant problems in the event of a claim. In the worst-case scenario, the insurer may refuse to pay, so the urgently needed disability pension is not paid out. Especially in the event of a claim, when the policyholder is dependent on disability benefits, such a refusal can threaten their existence. For this reason, it is advisable to take enough time to complete the application and answer all questions conscientiously. Uncertainties should never be underestimated – if in doubt, the support of a specialist lawyer for insurance law or an independent insurance expert can help avoid mistakes and secure insurance coverage.
The pre-contractual duty of disclosure is also of great importance when it comes to enforcing claims in the event of an insurance claim. In the event of a refusal of benefits on the grounds of an alleged breach of the duty of disclosure, the policyholder can only successfully assert their claims if they can prove that all questions were answered correctly and completely. In such cases, professional assistance is often essential to protect one’s rights and obtain disability benefits.
In summary: The careful and truthful answering of health questions when taking out disability insurance is the basis for reliable coverage. Those who proceed carefully and seek expert advice if in doubt can protect themselves against later problems and increase their chances of receiving the agreed disability pension if the worst comes to the worst.
Medical evidence is crucial
What is decisive for an insurer’s obligation to pay disability insurance is the medical evidence of a permanent reduction in occupational ability of at least 50 percent. If there is a dispute over the insurer’s obligation to pay, policyholders should seek legal advice to enforce their claims. Specialized attorneys can significantly improve the chances of success in asserting claims against the insurer.
MTR Legal Rechtsanwalt advises in insurance law and with problems relating to disability insurance.
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