Loss of earnings should be mitigated by the disability insurance. The BU insurance pays if you can no longer work for health reasons. But what if you have survived an illness and can actually go back to your last job? Does this automatically end the entitlement to benefits from your disability insurance? And what if the BU insurance limited the benefits from the outset?
Limitation of the BU pension only in exceptional cases
First of all, it should be noted that a time limit for the BU services is only permitted in exceptional cases. According to Section 173 (2) VVG, recognition of the BU may only be limited in time once. In addition, the requirement for a specific reason for a time limit is specified in many conditions. From this it follows that a limitation of the benefits from the occupational disability insurance is only permitted if there is an actual factual reason, which you as the policyholder must also be informed of.
Loss of entitlement to BU services
In the normal case, i.e. if there is no time limit for the BU benefit, the entitlement to payment of the monthly BU pension remains until the BU insurance proves in a review procedure that the prerequisites for occupational disability are no longer met. Evidence that you can do more than 50% of your previous professional activity must be provided by the insurance company. Whether this is actually the case must be clarified by an expert opinion. A mere assertion by the insurance company that the requirements no longer exist is not sufficient here.
BU pension despite being able to work?
But what if the insurance company has wrongly set a time limit for the benefit or has not properly justified the time limit?
The BGH ruled with judgment of October 9th, 2019, Az. IV ZR 235/18 (http://juris.bundesgerichtshof.de/cgi-bin/rechtsprechung/document.py?Gericht=bgh&Art=en&az=IV%20ZR%20235/ 18 & nr = 100781) determined that the insurer may be obliged to provide benefits, even if the person is again able to work, i.e. the prerequisites for the conditional disability are actually no longer present.
In the opinion of the BGH, an insurer cannot invoke the time limitation of the benefit if this is not adequately justified.
According to the conditions, the time limit for recognition initially presupposes the existence of an objective reason. A time limit should only be possible in such justified individual cases. In the event that such a factual reason exists, this must also be communicated to the policyholder. A temporary acknowledgment is only effective if these two requirements coincide.
If such an invalid acknowledgment is issued, the insurer’s obligation to provide benefits does not in fact end. The termination of the further obligation to provide benefits can only be achieved through a review procedure by the insurer. According to § 9 of the model conditions for occupational disability insurance (https://www.gdv.de/resource/blob/6326/790e00a54ae62b9c58aa7a0f3c3b765a/01-allgemeine-bedingungen-fur-die-berufsunfahigkeits-versicherung-0-pdf-data.pdf) However, the insurer will only be exempt from payment for the future on the basis of its findings in the review procedure, so that a reclaim is ruled out.
What does that mean for me?
If you have received temporary benefits from your occupational disability insurance, you should have it checked whether the temporary limitation of the BU benefit was even permissible under the conditions and, if so, whether the limitation was properly justified. If this is not the case, there is a chance that you are still entitled to benefits from your occupational disability insurance, as a review procedure has not taken place.
I will be happy to assist you with any questions you may have about disability insurance.
Best regards
Dominik Engelhardt
Lawyer
Specialist lawyer for medical law
Photo: Unsplash / Alleff Vinicius
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