Most rejected claims fail on the definition, not on an exotic exclusion clause. German law requires a sudden event acting on the body from outside that involuntarily causes a health impairment. Add the hard deadlines, usually 15 months for the disability to occur, to be certified by a doctor and to be claimed, and the cut when illness contributed at least 25 percent.
What a cut costs, what fighting back costs, and what a tariff with longer deadlines and a higher threshold costs.
Example
Typical range
Cut at 25 percent contribution, basic sum EUR 100,000, degree of disability 20 percent
EUR 20,000 becomes EUR 15,000
Cut at 50 percent contribution, same figures
EUR 20,000 becomes EUR 10,000
Your own counter-report by a medical expert
about EUR 1,500 to 5,000, depending on field and effort
Standard tariff, office job, basic sum EUR 100,000
about EUR 60 to 180 a year
Tariff with a 50 percent threshold and 24-month deadlines, office job
about EUR 90 to 250 a year
Guide values as of September 2026.
The reduction examples are calculated from the model terms,
the expert fees come from publicly quoted fee ranges.
The premium range for tariffs with longer deadlines and a high threshold is a guide value from
day-to-day quoting practice.
Your own policy wording decides your case, not the model terms; we obtain the exact quote for you.
Worked example
Shoulder injury with arthritis, age 52
A fall from a bike leaves the shoulder permanently restricted. This is how the insurer calculates when a pre-existing condition contributed, and how the same case would look on better terms.
Basic sum
EUR 100,000
Degree of disability for the arm under the scale (Gliedertaxe)
35 percent
Contribution of the arthritis per the medical report
40 percent
Accident-related degree of disability
21 percent
Payout on standard terms
EUR 21,000
Payout on terms that waive the contribution
EUR 35,000
The same injury, a difference of EUR 14,000, purely because of one clause in the wording.
The definition: four parts, all of them needed
German policies insure an accident, and the law defines it narrowly: a sudden event acting on the body from outside that involuntarily causes a health impairment (section 178 paragraph 2 of the Insurance Contract Act, Versicherungsvertragsgesetz). If one of the four parts is missing, there is no payout, however serious the damage feels.
This is where most rejected claims fail. A slipped disc while lifting a box has no outside event, nor does a heart attack during sport, and wear and tear built up over years is not sudden. Stumbling and falling when you step from a boat onto a jetty, on the other hand, ticks all four boxes.
Part of the definition
What it means
Where claims usually fail
Sudden (plötzlich)
the event acts within a short period
wear and tear over years, constant strain at work
From outside (von außen)
the cause comes from outside the body
slipped disc while lifting, heart attack, stroke
Involuntary (unfreiwillig)
you did not want the injury
deliberate self-harm, planned surgery
Health impairment
the body is demonstrably damaged
a fright without injury, damage to property only
Your own movement and increased exertion
If you injure yourself while standing up, twisting or sprinting, nothing acts from outside, so the strict definition would not cover it. That is why almost every good tariff adds an extended definition (erweiterter Unfallbegriff): it also counts as an accident if increased exertion (erhöhte Kraftanstrengung) dislocates a joint in your limbs or spine, or strains or tears muscles, tendons, ligaments or capsules. Exertion is increased when it goes beyond the normal movements of daily life.
The limit is written into the policy wording and is easy to miss: the meniscus and the discs of the spine are neither muscles nor tendons, ligaments or capsules. A torn meniscus from your own movement is therefore not covered even under the extended definition, unless the tariff names it explicitly. A ruptured Achilles tendon during a sprint is covered.
The deadlines that kill a claim
Three deadlines decide the disability benefit. Under the model terms (Allgemeine Unfallversicherungsbedingungen), the disability must have occurred within 15 months of the accident and be certified in writing by a doctor within the same 15 months, and you must notify the insurer within 15 months. Older wordings give one year for the onset and 15 months for certification and notice. Better tariffs extend this to 18, 24 or even 36 months, which is exactly what to compare before you sign.
This is not a polite reporting deadline, it is a condition of the claim. Miss it and the benefit is gone; only special cases excuse it, for example a serious head injury. Practical advice: write to the insurer early to say that you expect permanent disability, even while treatment continues. If your condition later worsens, you and the insurer may have the degree of disability reassessed up to three years after the accident, longer for children.
Deadline
Standard wording
Better wording
Report the accident
without delay (unverzüglich)
without delay, this does not change
Disability has occurred
15 months, older wordings one year
18 to 24 months
Certified by a doctor
15 months
24 to 36 months
Claimed with the insurer
15 months
24 months
Ask for reassessment
three years, longer for children
five years and more for children
Limitation period
three years, from the end of that year
statutory, not negotiable
Pre-existing conditions: the most common cut
Only the consequences of the accident are insured, not illness and infirmity. If a pre-existing condition contributed to the injury or its consequences, the degree of disability is reduced by that share (section 182 of the Insurance Contract Act). The model terms give a plain example: a leg injury leaves a degree of disability of 10 percent, rheumatism contributed 50 percent, so 5 percent remain. Below a contribution of 25 percent there is no reduction at all.
In practice this hits almost everyone over 45 with a shoulder, knee or back claim, because a medical expert will nearly always find some wear. Two things help. First the contract: good tariffs only count a contribution from 50 percent, very good ones waive it entirely. Second the burden of proof: the insurer has to prove the pre-existing condition, its concrete share and that the threshold is passed. An MRI report with a blanket percentage is not proof, and an assumption certainly is not.
The classic exclusions
Excluded accidents are: accidents you cause deliberately (section 183 of the Insurance Contract Act), accidents caused by disturbances of consciousness (Bewusstseinsstörung) as well as by strokes and seizures, accidents while deliberately committing a criminal offence, war and civil war (exception: you are surprised by it while travelling abroad, cover then ends at the end of the seventh day), accidents as the pilot of an aircraft or air sports device, taking part in motor races, and accidents caused by nuclear energy. A disturbance of consciousness can come from illness, medication, alcohol or drugs. The model terms name no blood alcohol limit; what counts is whether your perception and reaction were no longer up to the danger at hand. For car drivers, courts assume this from roughly 1.1 per mille, later for cyclists, and some tariffs set their own, higher limits.
There are also excluded health impairments, whatever the accident looked like: damage to spinal discs and bleeding from internal organs (exception: the accident caused more than 50 percent of it), radiation damage, damage from medical treatment or surgery (exception: the treatment was caused by an insured accident), infections (exceptions: rabies, tetanus, tick-borne encephalitis after a tick bite and germs that entered through more than minor wounds), poisoning by swallowing, pathological disorders following psychological reactions, and abdominal or lower abdominal hernias. The last group surprises many people: post-traumatic stress after an accident is excluded, organic brain damage is not.
Pays, does not pay, or pays less
The table lists the cases that cause most of the disputes. It follows the model terms; your own policy may be better if it has the extended definition, longer deadlines and a high threshold for pre-existing conditions.
Read the middle column together with the right one. A rejection is one company's view of a set of facts, not a judgment. In the cases marked as reduced, a second medical opinion is almost always worth the trouble.
Case
Outcome
What to do
Fall from a bike, shoulder stays permanently stiff
pays
get the disability certified within the deadline
Slipped disc while lifting a box
does not pay
check income protection and sick pay instead
Heart attack while jogging
does not pay
a matter for health and income protection cover
Knee damage with arthritis as a pre-existing condition
pays less
ask for the report and the contribution rate
Achilles tendon tears during a sprint
pays with the extended definition
read the clause on increased exertion
Torn meniscus from your own movement
usually does not pay
check for an add-on, the meniscus is excluded
Car crash with a high blood alcohol level
often does not pay
have the level and the clause checked
Tick bite with tick-borne encephalitis
pays
have the bite and the infection documented
Anxiety after an accident
does not pay
psychological reactions are excluded
Disability reported after 20 months
does not pay
only an excusable delay is accepted
If the claim is rejected or cut
First ask for the full reasons and for the medical report the insurer relies on. Then work out what the rejection really rests on: a deadline, an exclusion or a contribution rate. Each of the three is attacked differently. Against an assessment, a fresh medical opinion helps; against an inflated contribution rate, a counter-report; and if your condition has worsened, ask for the degree of disability to be reassessed within three years of the accident.
If the answer stays no, a complaint to the insurance ombudsman (Versicherungsombudsmann) is free: up to EUR 10,000 in dispute the decision binds the insurer, up to EUR 100,000 the ombudsman issues a recommendation, and you may still go to court afterwards. Claims become time-barred after three years, counted from the end of the year in which the claim arose and fell due. The old short deadline for filing suit after a rejection was abolished in 2008. Policy wording and claim letters are in German, and the German wording is what counts.
Step by step
Report the accident without delay and see a doctor, even if the consequences are unclear.
Write early to say that you expect permanent disability; that protects the deadline.
Obtain a written medical certification of disability before the 15 months run out.
If the payout is cut, ask for the report, the contribution rate and the reasoning.
Ask for a reassessment within three years if your condition gets worse.
Checklist
Contribution of illness counted only from 50 percent, or waived entirely
Deadline for onset and medical certification extended to at least 24 months
Extended definition of an accident covering your own movement and increased exertion
Spinal discs and meniscus included where the tariff offers it
No low fixed blood alcohol limit in the wording
Longer reassessment period for children
Common mistakes
Letting the 15 months pass because treatment is still going on
Accepting a cut for a pre-existing condition without reasons and without the report
Reporting the accident only once permanent damage is certain
Comparing premiums only and ignoring deadlines, thresholds and the definition
Questions and answers
Frequently asked
Does accident insurance pay for a slipped disc?
Only if an insured accident caused it predominantly, meaning more than 50 percent.
Lifting a box with no outside event is not an accident.
Does it pay after a heart attack during sport?
No, a heart attack is an illness.
If you fall because of it and get injured,
the exclusion for disturbances of consciousness applies on top.
What about drink driving?
The model terms name no limit in per mille.
What counts is whether your perception and reaction were no longer up to the situation;
for car drivers courts assume that from roughly 1.1 per mille.
Can I challenge a cut for a pre-existing condition?
Yes.
The insurer must prove the condition, its concrete share and that the threshold is passed.
A blanket percentage taken from an MRI report is not enough.
What does a complaint to the ombudsman cost?
Nothing.
Up to EUR 10,000 in dispute the decision binds the insurer,
up to EUR 100,000 you get a recommendation,
and the courts stay open to you.
Can a missed deadline be saved?
Only in special cases, for example after a serious head injury.
You then have to give notice without any further delay.
Does it cover the psychological effects of an accident?
Pathological disorders following psychological reactions are excluded, even after an accident.
