When does accident insurance not pay in Germany?

What a cut costs, what fighting back costs, and what a tariff with longer deadlines and a higher threshold costs.

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.

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.

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.

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.

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.

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.

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; as your underwriting agent we read the reasons with you and draft the complaint.