Legal position after your occupational disability claim is rejected
If the insurer rejects the occupational disability pension, it must state this in text form under § 173 (1) VVG. The reason given determines where an objection can start. As long as the claim is registered with the insurer and no decision has been made, limitation is suspended under § 15 VVG. Our lawyers in Augsburg review the decision letter and the policy conditions.
Reasons why occupational disability claims are rejected
A rejection usually follows one of three patterns. The insurer disputes that you meet the contractual degree of disability, relies on a breach of the pre-contractual duty of disclosure, or considers the medical records incomplete.
You are occupationally disabled under § 172 (2) VVG if, as a result of illness, injury or a decline in strength beyond what is normal for your age, you are presumably permanently unable to perform all or part of the occupation you last carried out. The benchmark is that occupation in the specific form it took before the illness. § 172 VVG names no percentage; the 50 percent threshold comes from the insurance conditions, not the law.
The second pattern concerns the pre-contractual duty of disclosure. Under § 19 (1) VVG you only have to disclose circumstances relevant to risk that the insurer asked about in text form. Its rights under § 19 (2) to (4) VVG apply only if it separately informed you in text form beforehand about the consequences of a breach of this duty (§ 19 (5) VVG).
These rights are time-limited. The insurer must assert them in writing within one month (§ 21 (1) VVG). They lapse five years after the contract was concluded, or after ten years in cases of intentional or fraudulent breach; that lapse does not apply to insured events that occurred before this period ends (§ 21 (3) VVG).
Deadlines and limitation after a rejection
Three routes remain open after a rejection: an objection to the insurer, proceedings before the insurance ombudsman, and a claim for payment before the civil courts. The VVG sets no deadline for an objection itself; the only time limit comes from the limitation of the underlying claim.
The claim becomes time-barred after three years (§ 195 BGB). Under § 199 (1) BGB the period begins at the end of the year in which the claim arose and you became aware of the circumstances giving rise to it, or would have become aware but for gross negligence.
The period stands still while the insurer is examining the claim. If the claim has been registered with the insurer, limitation is suspended under § 15 VVG until the insurer’s decision reaches you in text form. Only that receipt sets the period running again.
Which court has jurisdiction depends on the value in dispute. For recurring benefits such as an occupational disability pension, § 9 ZPO calculates this as 3.5 times the annual amount. Up to €10,000 the Local Court decides (§ 23 no. 1 GVG); above that, the Regional Court (§ 71 (1) GVG).
Objection and litigation against the rejection
The objection addresses the reasoning given in the rejection letter. Depending on the pattern of rejection, we examine the conditions on the degree of disability, the notice required under § 19 (5) VVG, or the medical records. If the insurer maintains its decision, litigation follows.
Reviewing the rejection letter
First we examine the letter itself. § 173 (1) VVG requires a statement in text form on whether the insurer accepts its liability to pay. A time-limited acknowledgment is permitted only once and is binding until it expires (§ 173 (2) VVG).
If the insurer relies on the degree of disability, we compare its assessment with your occupation by task, time proportion and physical strain. The objection sets out the discrepancies and is supported by medical opinions and a description of your occupation.
Litigation before the competent civil court
If payment is not made, we sue for the claim. An assessment obtained by the insurer does not bind the court. The court decides on occupational disability according to its own free conviction (§ 286 (1) ZPO), generally on the basis of an expert it selects itself (§ 404 (1) ZPO).
Common mistakes after a rejection
Most disadvantages after a rejection arise from your own statements. What you tell the insurer, your treating doctors and the pension insurance provider is later set side by side in any proceedings and checked for contradictions. Careless wording supplies material against your own claim.
Silence or premature acceptance
Not responding changes nothing about the rejection. Once the decision reaches you in text form, the suspension under § 15 VVG ends and the three-year period under § 195 BGB continues to run.
The second mistake is agreeing too quickly to a settlement. Any lump sum offered should be measured against what the agreed monthly pension would total by the end of the benefit period.
Incomplete or contradictory statements in the objection
Blanket statements without medical evidence weaken the objection. Set out which specific tasks you can no longer perform, to what extent, and which medical findings support that.
Make sure that what you tell the insurer, your doctors and the pension insurance provider is consistent. Contradictions between the claim application and rehabilitation reports are a frequent point insurers attack.
Further information
These topics may also be of interest:
This information does not constitute legal advice in an individual case.
