September 26, 2022 – For questions related to health, everything requested by the insurer must be given in text form. To avoid problems, it is advisable to follow the spirit of the questions and not the letter. When examining a medical record, complacent diagnoses are a problem. Ultimately, everything should be presented to the subscriber clearly and ready for a decision. Fairness to the insurer also means fairness to the broker and the client, writes Philip Wenzel in his guest article. The text is an excerpt from a recent presentation by the biometrics expert.
If an intermediary writes something on health topics without legal examination by the state, this should of course be treated with caution. However, even the fully qualified attorney says with each question that it depends on the individual case. That is why I am going to allow myself to logically deduce what to look for in health matters to get a good vote from the insurer with the greatest possible legal certainty.
Indicate everything that the insurer asks for in text form
- Philip Wenzel (Image: Doris Koehler)
It must be said in advance that I approve of health problems and am skeptical of simplified health checks. Because health issues keep the group clean in the early years and prevent the accumulation of claims. Therefore, it is about finding the best possible solution for the individual without endangering everyone else in the collective.
The room for maneuver here is relatively small, because basically everything that the insurer asks for must be specified in text form. Only trivial diseases are not specified, that is, diseases that everyone has once and that heal themselves without consequences.
In addition, you only have to give the result of a genetic test if you are going to insure more than 30,000 euros of annual pension or an insured sum of 300,000 euros. However, if the person concerned already had complaints pointing to the detected genetic defect, then he or she should still mention it.
Pay attention to the consultation period
Anything that falls under the general Equal Treatment Act should also not be listed or can be elegantly circumvented. For example, it is perfectly fine to simply report a pregnant woman’s pre-pregnancy weight. Of course, it should be noted that it is not the current weight. But this does not have to be specified due to the AGG.
It is important to pay attention to the consultation period. If the diseases are cured outside this period, then they do not need to be included. But everything that remains must be declared even if it has not caused any complaints for a long time. The classic here is scoliosis, which was once diagnosed in youth. It usually does not heal.
However, if an existing disease has no treatment and no symptoms, then nothing stands in the way of a normal assumption.
Personally, I don’t want any trouble, so I follow the spirit of the questions and not the wording.
Follow the meaning of the questions and not the wording
When it comes to interpreting health problems, it depends on whether you want to be right in the end and would also enforce it in court or whether you want insurance coverage that won’t cause problems later on.
Personally, I don’t want any trouble, so I follow the spirit of the questions and not the wording. If an insurer only asks about longer stays outside of Europe, it would still indicate whether the client wants to move to Ukraine permanently. Even if she moves to Austria, she would ask beforehand. In the rarest cases there is a problem here.
In extreme cases, it could be argued if a customer who has only been on sick leave for 13 days can still check in quickly if health-related questions are asked after 14 days.
Perhaps I am being too cautious, but the Bundestag form 16/3945 says very clearly that in case of fraudulent intent one must also indicate what the insurer did not ask for. A good attorney can argue in court that the insurer is intentionally not asking for business. So you have to take the risk that someone will take advantage of it. But protection is on shaky ground for the first ten years.
As such, the insurer must decide what is important and what is not.
The biggest problem with all medical records is complacent diagnoses.
With the obligation to inform that it is always an issue of this type. Personally, I try to absolve myself first of all, since I never know if the client is not lying to me to reassure me. However, it is not my job to check if the client is lying to me. That way I don’t have to take out the medical history and check that everything is invoiced.
On the contrary, once I have seen the file, I must declare everything it contains. Anyone who dares can take out minor illnesses. But the insurer has to decide what is important and what is not.
And the biggest problem with any file is complacent diagnostics. These are statements that are not true, but that the doctor has made many times in favor of the client. Some talk about billing diagnostics. Perhaps a doctor wanted to be nice and then billed an illness so the client could get an extra day of vacation or not have to go back to their old job after termination.
Even if these diagnoses are obviously wrong, we must establish and explain them. And the explanation must be credible.
The biggest problem with each file is the complacent diagnostics.
In the case of a performance, it comes out
If you don’t get the file, you’ll end up with complacent diagnostics in the event of a claim. That’s basically a bad thing. However, if service is denied, the insurer must prove that the customer was aware of the bill. And that is really only possible with sick leave, medication or hospital stays.
Therefore, the file should only be obtained if the client knows of a medical leave that the doctor gave him as a courtesy. Then there is an accounting behind it that needs to be explained.
Everything must be presented to the subscriber clearly and ready for a decision.
Think inside the subscriber
If an intermediary wants to achieve a better result, all they really have to do is think of a subscriber. Because he always has to assume the worst. Therefore, everything must be presented clearly and ready for a decision.
If the client uses an asthma spray, for example, then the information that he only takes it “when needed” doesn’t help. Because that can happen several times a day. However, if it is reported to the insurer, if this is true, that the asthma spray was last used four years ago and the applicant continues to prescribe it for emergencies, then the insurer may very well be able to waive the exclusion clause. .
The insurer will also not like the “2018 ski accident, healed without consequences”. Because we don’t know what happened at all. Was it the knee, the arm, the head? Or just a crooked thumb? Here it may be that the consequences of the accident no longer need to be treated, but the aneurysm in the head and the osteoarthritis in the knee are currently symptom-free.
It is convenient that intermediaries behave fairly with the insurer.
Behave fairly with the insurer
If the insurer has all the information and now decides that a surcharge or rider is necessary, then you’re not done yet. Because clause and surcharge only want to limit the insurer’s risk.
Sometimes it is also possible to limit it if you opt for a shorter term, do without dynamic or post-insurance guarantees, or start a lower pension. So what makes sense in individual cases always depends on what the lawyer would say.
The bottom line is that it helps to present everything to the subscriber in an understandable and decision-ready way. Personally, I believe that it is convenient for intermediaries to behave fairly with the insurer, because we want to be treated fairly in the event of a claim.
In the current VersicherungsJournal podcast (VersicherungsJournal September 22, 2022), Philip Wenzel describes how he assesses the influence of the coronavirus pandemic on disability insurance. In a previous edition of the podcast (01/07/2021), two subscribers explain what constitutes an effective preliminary consultation for BU insurance.