An insurance company cannot rely on the late notification of an insured event if the policyholder was unable to report the insured event himself or to inform her authorized husband due to her state of health and the husband had no knowledge of the insurance contract (daily care allowance insurance). That’s what the Higher Regional Court of Frankfurt a. M. (7 U 36/19) decided.
The plaintiff asks the defendant insurance company to provide retrospective daily care allowance for his wife, who has since passed away. This maintained a daily care allowance insurance with the insurance company in the event of a need for extreme care (care level III). The general insurance conditions stated, among other things: If the application is made after the end of the month in which the insured event occurred, the entitlement to benefits is given from the beginning of the month in which the application is made. However, if the insured event is reported late through no fault of its own, the benefits will be provided retrospectively.
The plaintiff had a health care proxy for his wife. In 2012 she suffered a severe stroke with one-sided paralysis, complete loss of speech and considerable impairment of memory. In 2013 she received care level III. The plaintiff reported the insured event in 2015 and applied for retrospective benefit provision from 2013. The insurance company refused.
The LG dismissed the action. The appeal lodged against this was successful. The insurance cannot rely on late notification of the insured event in accordance with the general insurance conditions. The late notification was made through no fault of our own. In principle, the policyholder must report the insured event himself. However, due to the stroke, the woman was not able to report it herself or to inform the plaintiff about the insurance in question. Nor did it have to inform the plaintiff about the existence of the insurance contract before the occurrence of the insured event, in the sense of a proactive behavioral obligation. Such a “pension obligation” does not exist.
The plaintiff himself was also not culpably neglecting to report the insured event earlier in a manner attributable to his wife. He had no knowledge of the existence of this contract through no fault of his own. The monthly direct debits of the insurance premiums of EUR 20, known to him, did not give any reason to assume such an insurance. From the booking text it emerged that there was some kind of insurance contract with the insurance company, but nothing about the type of insurance.
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