OGH on Accident Insurance Coverage for Pre-existing Conditions

May 3, 2024 Benn-Ibler Rechtsanwälte

Pre-existing illnesses and infirmities lead to reduced benefits in the event of insured accident injuries.

The applicant in the case at hand suffers from atypical Parkinson’s disease. This is a neurodegenerative disease that can lead to an increased risk of falling. In 2017, she suddenly felt a sharp pain in her left calf, accompanied by a distinct snapping sound. It turned out that she had torn a tendon in her ankle joint. The rupture was 100% the result of chronic degenerative changes.

The plaintiff claimed disability benefits from her accident insurer, as she was now 50% permanently disabled because of the accident. She did not have any other pre-existing medical conditions or infirmities. However, the defendant accident insurer applied to dismiss the claim, stating that the ruptured tendon had not been caused by an accident, as the plaintiff was suffering from a previous degenerative injury.

The lower courts dismissed the case.

According to the pertinent accident insurance contract, dislocations of limbs as well as sprains or ruptures of the limbs, muscles, tendons, ligaments, and cartilage located on the spinal column as well as meniscus injuries are considered to be accidents. However, in the case of disability, the percentage of the degree of disability will be reduced if illnesses or infirmities which existed prior to the accident have contributed to worsened health caused by the accident or its consequences.

The contract therefore provides for a de facto limitation of the insurance coverage in that an insurance benefit is only paid out for consequences caused by the accident. In other words, the insurer is only liable for those consequences for which the accident is (solely) responsible. The average policyholder’s understanding of this provision is that illnesses or infirmities that are unrelated to the accident are generally at the policyholder’s expense, i.e., that the claim is reduced.

In the case at hand, the chronic degenerative changes caused by Parkinson’s disease were the cause of the accident. There is no insurance coverage due to the 100% causation of an accident in the insured injury – and thus necessarily in the permanent disability caused by it.

OGH 7 Ob 3/24b (6 March 2024)