– A young woman suffered a serious traffic accident and was hoping for insurance against occupational disability. But the provider didn’t pay – and the 27-year-old lost at the Nuremberg-Fürth regional court. She had given inadequate answers to questions about her health. An avoidable mistake.
80 percent of all applications for occupational disability pension (BU pension) are approved – the Association of the German Insurance Industry (GDV) officially announces this and it sounds like just a stupid prejudice that it could be part of the industry’s business model, in case of doubt, more not to pay. However, this figure also shows that around 20 percent of those affected fear or have to argue about the BU pension.
Name previous illnesses
But what reasons do the companies cite when they refuse to pay? Anyone applying for a BU pension will receive a sheet from the insurance company and many questions have to be answered. It’s about clinical pictures and medical treatments – and previous illnesses are also queried very precisely.
Anyone who knows that an insurance company carefully checks all components of the contract before paying and researches the insured person’s medical history can at least avoid their own mistakes – as a current judgment of the Nuremberg-Fürth Regional Court (11 O 4279/20) shows: One A 27-year-old woman from Lower Bavaria requested a BU pension from the Nuremberg life insurance company. The insurer refused to pay, and rightly so. The 11th Civil Chamber dismissed the woman’s complaint. She did not specify several previous illnesses when the BU contract was signed.
Not a cent is paid for inconsistencies
A frequent mistake, as the GDV statistics show: 14 percent of the EU pensions applied for are not paid out because the policyholders “violated pre-contractual reporting obligations”, according to the legal formulation. In plain language: if there are inconsistencies, not a cent will be paid.
The dispute: The plaintiff, at that time she was still a trainee, took out a business insurance policy through a financial advisor in September 2012. Because she was only 17 years old, her mother also signed the contract. The monthly fee was 32.09 euros, in October 2017 the contribution was increased to 49.69 euros, and savings should be made for old-age provision until autumn 2061. In addition, a BU pension should be due in the event of occupational disability or need for care.
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At the beginning of January 2019, the woman was involved in a serious accident with a pickup truck. The insurance company checked and found that the woman had stated that she had not had any health problems in the five years before the contract was signed. In fact, when she was twelve, the ophthalmologist prescribed her glasses. An orthopedic surgeon prescribed shoe insoles because of pain in her knees. And also a circulatory collapse in the vocational school was on record and a urinary bladder infection. Two weeks before the insurance contract was signed, she was diagnosed with migraines and had to go to the emergency room because a car ran over her left foot.
Don’t be too quick to sign: a contract takes time
From their point of view harmless little things. Can’t you assume that knee pain was due to puberty growth? And what do insoles for shoes and glasses have to do with a traffic accident? In addition, in the consultation at that time, the financial agent presented those questions on the health application form as insignificant. The financial agent claims the opposite today. She wants to have expressly emphasized how important the questions are.
And in the end, the insurance company assessed all the incorrectly answered questions from the policyholder as fraudulent misrepresentation.
It is easy to speculate today: Perhaps the financial advisor wanted to conclude the contract quickly in order to collect her commission, perhaps she even wanted to prevent inquiries from the insurer. The only thing that is certain is the unambiguous wording in the insurance application: “The Nürnberger Versicherung application review evaluates risk and healthinformation. Please answer the information on the state of health completely and correctly. This is the only way to ensure that your insurance cover is actually effective.”
There is a lot of money involved – so there is no goodwill
“The pre-contractual obligation to notify is a legal obligation,” says Justice Spokesman Friedrich Weitner. Future policyholders who don’t look closely, quickly find themselves in an unpleasant contract and – like the young woman from Lower Bavaria – get nothing. The check is easy for the insurance company: You can find out from the family doctor and the treating specialists whether illnesses occurred in the years before the contract was signed. If visits to the doctor are discovered that were not specified, the company will withdraw from the contract.
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The Insurance Contract Act protects the insurance company and the collective of insured persons. And since there is a lot of money involved, there is no goodwill here. Anyone who temporarily had back pain must expect that the insurance will later evaluate this as the first sign of a later musculature or bone disease.
Lawyer Weitner therefore recommends not to be rushed by intermediaries, but to take your time. The insurance company must ask its questions in writing and the answers must also be in writing. And the future policyholder only has to state what they are actually asked about. For this reason alone, it can be worthwhile to seek advice from your family doctor when you are filling out the questionnaire. Reinsurance by an insurance law attorney is also recommended.
Do not answer more than is asked
Broad questions are also permitted, for example about complaints, disorders or illnesses in the past ten years. If, for example, the heart is addressed, the policyholder does not have to add, without being asked, that his digestion is sometimes a problem. Not every flu-like infection needs to be mentioned, on the other hand, minor illnesses, if they accumulate, can point to an impaired immune system.
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According to Justice Spokesman Friedrich Weitner, the Insurance Contract Act draws a line if the questions go so far that a policyholder has to risk making a misjudgment. “Are you perfectly healthy at the moment?” or “Did diseases ever exist” would be far too generalized.
Questions that are not asked cannot be answered incorrectly, the Federal Court of Justice (Az .: IV ZR 218/95) determined: In this specific dispute, an insurance company (wrongly) refused to provide benefits because the policyholder did not ask any questions about the Health had answered. But in the evidence it turned out: The insurance agent had only asked the customer about his size and weight. This proves that no policyholder has to voluntarily reveal health problems – if the questions are not asked. And if the representative considers information on allergies, spa stays or visits to the doctor to be superfluous, this cannot be borne by the policyholder.
An insurance agent before the Munich Higher Regional Court (Az .: 25 U 5827/07) admitted that he had not noted the insured person’s back pain two years ago, after all the pain had already subsided. The policyholder was later unable to work due to spinal complaints.
In an insurance contract that was employed by the Karlsruhe Higher Regional Court (Az .: 12 U 156/16), no health questions were asked at all. On the application for the occupational disability insurance there was only a “declaration” to be read, which the policyholder should confirm with a cross: “I declare that to this day I have neither had a tumor (cancer) nor an HIV infection (positive AIDS Test), a mental illness or diabetes mellitus (diabetes) has been diagnosed or treated. “
Willful deception
The policyholder, who at this point already suffered from multiple sclerosis, did not report this disease. Since the insurer had not asked about it either, it was not obliged to do so. Nevertheless, the judges saw malicious deception. The policyholder’s lawsuit failed – but for other reasons. The man – this documented report – has not been able to practice his profession without restrictions for a long time. But in the contract he ticked the wrong place and claimed: “I am able to pursue my professional activity to the fullest.”
