When does the insurance company refuse to pay

Insurance doesn't pay

What to do if the insurance company does not pay

There are several reasons why insurance won't pay. Ultimately, the decisive factor is whether the non-payment of the insurance is justified or not. The possible procedure, including the legal options for insurance customers, is briefly explained below in a small checklist. The links to other Finanztip articles explain the variants in detail.
Are you accused of breaching an obligation? Sometimes the damage is not covered by the insurance policy or there is underinsurance or the damage was reported too late or not adequately documented. But other reasons such as deliberately slow regulation by the insurer occur again and again.

Small checklist if the insurance does not pay

First of all: Don't lie, don't gloss over anything or twist facts. How the Finanztipp article Must insurers reimburse attorney fees? shows, you shouldn't rush to hire a lawyer for simple insurance damage who should claim the insurance damage if you don't want to pay the legal fees yourself. In principle, the policyholder has to prove the amount of the damage, although no high demands may be made on the provision of evidence. Depending on the insurer's argumentation, a graduated approach is recommended in the event of non-performance. As long as the insurance company has not yet received a definitive letter explaining the reasons for the non-payment, it is first necessary to remind you that it will be dealt with soon. This can already make it clear that in this specific case the insured will get into financial difficulties if the insurance does not pay quickly. Points of a checklist:

  • Remind them by letter - possibly by setting a deadline
  • Follow up by letter to the "Complaint Management" of the insurance company
  • Check whether there is an incorrect or unjustified entry in the database in the HIS
  • Send a complaint to the ombudsman
  • Submit a complaint to BaFin
  • Check whether the process is covered by legal expenses insurance or whether legal aid can be considered.
  • Hire the right lawyer for the insurance case.


Sluggish regulation of the insurer

Especially with larger sums and personal injury, the victims sometimes have to wait a long time for the compensation to be paid. It is true that the insurer has the right to examine the reasons and the amount of the claims in detail. A deliberate or inadmissible long delay in the performance of the insurer is not tolerated by the jurisprudence. In particular, judges have punished inadequate regulatory behavior in the payment of compensation for pain and suffering. If the insurance company does not meet its obligation to provide benefits after a reasonable examination period, payment will be delayed and the insurance company will also be responsible for the damage caused by the delay. The fee for the lawyer who reminds the insurance company to pay benefits may also count towards the damage caused by delay.

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Examples of case law in the event of sluggish regulation by the insurer

If an insurance company delays settling the claim for an inadmissibly long time, it must expect that the judiciary will give it negative credit for this behavior. For example, compensation for pain and suffering can be increased significantly, as the judgment of the Schwerin Regional Court of 06/26/2000 - 7 0 600/97 - shows. The judges therefore awarded the plaintiff higher compensation for pain and suffering. Similar to OLG Koblenz with judgment of December 22nd, 2000 - Az 10 U 471/99: The sluggish settlement of accidental damage (here 5 years, 2 months after the accident) is a delay in payment and increases the compensation for pain and suffering. The court also ensured that the insured was reimbursed for the costs of a lawyer because the insurance company refused to answer for the accident damage.
If the injuring party or his liability insurance company delays settlement of the claim contrary to good faith, the injured party is to be awarded a significantly increased compensation for pain and suffering as a satisfaction.
When calculating the compensation for pain and suffering, it must be taken into account if a claim settlement is only hesitant, although the obligation to pay was undoubtedly given and the injured party did not make any unrealistically high demands, or if the delay and the behavior of the insurer itself cause further emotional impairment of the injured party Have consequence. However, an increase in compensation for pain and suffering is not necessary if the insurer merely does not actively participate in the settlement of the claim, also because it is primarily up to the injured party to submit the facts supporting his claim to the injuring party (Brandenburg Higher Regional Court of October 12, 2006).

Previous damage in property insurance

Previous damage to property insurance must be stated when reporting the damage. Anyone who does not report previous damage must expect the insurer to refuse the benefit due to a breach of duty. Example from case law: The question asked in the form of the damage report about previous damage to a vehicle is to be understood from the point of view of an average policyholder in such a way that the question is asked about all previous damage and not just about the last previous damage (OLG Koblenz from January 15, 1999-10 U 1574/97). A comparable interpretation must also be observed in the event of a loss in private liability.
If the policyholder withholds significant previous damage when reporting a damage, the insurer is released from its performance because of a breach of obligation. The policyholder cannot claim that the previous damage was known to the insurer due to the storage of the corresponding information in the EDP, because this is not immediately available when the damage is processed, but can only be called up in the EDP after a corresponding decision by the clerk (Cologne Higher Regional Court of September 26, 2006 - 9 U 142/05).
The insurer's exemption from performance due to a breach of the obligation to provide information is not considered if the policyholder withholds a circumstance that the insurer is already aware of when reporting the damage. If the insurer has settled a previous damage within the framework of an ongoing insurance contract for a specific insured item, which is also relevant for the new damage report, he knows the details of this previous damage (BGH of 07/11/2007 - IV ZR 332/05).

Special case long-term care insurance

The need for care must be proven. If the application for benefits from long-term care insurance is rejected, you should first inspect the health insurance company or health insurance company in order to know exactly the reasons for the rejection. The applicant has several possibilities to collect arguments against the rejection. Example: If the person in need of care is already a customer of a care service, you can have the services of this service listed or your own family doctor can be consulted accordingly. The pedantic creation of a care diary should, if possible, be done before the medical service is assessed. In order to argue against the assessment of the medical service, an objection must be filed within one month of receipt of the rejection with the corresponding instructions on legal remedies. If the objection is rejected, there is only one way to go to the social court, which causes little costs.
The comparison: In many cases, reaching a settlement is a mutually acceptable solution. Example: Before you argue with the insurance company about what you think is the appropriate amount of the current value, it is better to "spare your time and nerves". It is not uncommon for insurance customers to "go over the top" when assessing the amount of their claim.

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