Disability coverage in insurance contracts

Incapacidad seguro

What types of disability covers your insurance contract?

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Disability coverages are risks commonly included in life insurance and accident disability cases. In this guide, We identify the different types of coverage and the most common issues that can arise in such insurance

The inability to hedge extra insurance contracts

The seguros de vida, under Article 83 Act 50/1980, of 8 October, Insurance Contract (onwards, LCS) they force themselves, mediante el cobro de la prima estipulada y dentro de los límites establecidos en la Ley y en el contrato, a satisfy the beneficiary capital, una renta u otras prestaciones convenidas, in the case death or survival of the insured, o de ambos eventos conjuntamente. Namely, the insured risk is death or survival.

Moreover, on accident insurance, regulated in Articles 100 and following the LCS (resulting from application also provided some provisions for life insurance) the insured risk is bodily injury resulting from an accident as violent causes, Sudden, external and beyond the control of an insured, to produce temporary or permanent disability or death.

Now, result very common Add in practice, these two types of insurance contracts, nail extra toppings consisting of ensure different types of disability that may occur. Namely, a main policy is carried out by life insurance or accident and supplemental policy annexed ensuring certain types of disability. Specifically, on accident insurance, It is added one Additional capital to the schedule if the disability is rooted in an accident

Difference between incapacity and invalidity

Law Insurance Contract does not make a clear distinction about the differences between the two concepts. Thus, to better understand the content of this guide, It is necessary to perform such differentiation.

So, the invalidity It is the situation where the person is following an accident that has caused an affectation to his state of physical or mental health. But, as it is affirming the civil jurisprudence, specifically the STS 21 December 2016, No.. 736/2016, “the declaration of invalidity, far from being the fact of causation of the damage or the loss, it is merely an administrative formality, determinant, inter, economic consequences in various aspects of the accident, but in no way can identify with it”.

Citing an example, It would be a situation of disability the situation recognized by the loss of a limb (a arm) after a traffic accident.

While, the inability It could be defined as the result generated by the disability. We must bear in mind that failure always linked to a professional activity.

For example, following the above case, if our affected professionally devoted to swimming, the loss of his arm would cause unable to perform their work. Now, if our affected was dedicated to telemarketer, the loss not incapacitate him for his professional activity and therefore, Serious undeclared incapacitated.

Therefore, the concept of disability is intrinsically linked to the idea of ​​compensation for loss and loss occurred health. Since disability is linked to a welfare benefit our own welfare state in the event that the invalidity, because of their importance and relationship, affecting the professional activity of the subject, incapacitating total form, partial or total and permanent.

Both economic concepts are Compatible.

Types of disability that can be found in insurance policies

 So good, It is true that our Supreme Court has reiterated that the degrees of disability under social legislation is not binding in resolving civil disputes. But, as stated in the judgment of the Supreme Court, Civil Division, of 1 March, No.. 233/2007, this does not preclude that could bring it up to them to define what the ordinary contours of the right of the insured. Namely, can be used definitions that Article 137 the Royal Decree 1/1994, of 20 June approving the revised text is approved by the General Law on Social Security done to know the situations comparable types of disability.

Indeed, Article. 104 the LCS states that "The determination of the degree of disability resulting from the accident take place after the submission of the medical certificate of disability ...". So this union so close between the two concepts and drinks necessarily invalidity for the delimiter concept of disability types follows.

Temporary disability:

It is a situation that prevents the exercise of the usual occupation for a certain specific period of time.

The cause of this disability may be due to illness or accident.

Here is where insurance covering these situations through daily payment of an amount of money similar or equivalent to perceive that if we could develop our professional activity.

An example would be sick and accident surgery a sprained ankle.

Partial permanent disability:

It is similar to the previous course, but with the difference that the result becomes perpetual in time and that yes allowed their professional activity.

An example would be the amputation of an arm in professions which is not essential to use this physiological faculty (telemarketer).

Permanent total disability:

The essential difference that keeps this situation permanent partial disability, is that this prevents the employee develop their usual occupation.

An example of this would be, dragging the previous course on the arm amputation, the insured professionally devoted to an activity inherent to the use of this member and therefore their loss would generate one unsuitability for their profession; Professional swimmer, pianist, etc..

Incapacidad permanente absoluta:

It involves physical and irreversible situation, determinant of all unfitness of the insured for permanent maintenance of any employment relationship, professional activity or occupation.

Namely, the worker you can not perform any professional or business activity; not only can no longer perform that which is coming devoting, but it will not be able, their physical or mental situation, perform any occupation.

In connection with the above examples, We could raise the case where the worker suffers a mental illness, as it could be a serious bipolar disorder.

severe disability:

Severe disability is a particularly distressing form of permanent injury or a set of them. Y is defined as a situation affection permanent disability worker who, by consequences of anatomical or functional losses, needs the assistance of another person for the most essential acts of life; such as dressing, travel, eating or the like.

Following examples illustrators, We could be looking at a hypothetical amputation of all limbs of a person, being completely prevented.

recurrent disputes in practice

The insured must faithfully answer health questionnaire presented

The insured is obliged to respond in good faith to the health questionnaire submitted by the insurer, putting this knowledge of all circumstances that may involve an increase in the insured risk.

In case of fraudulent concealment by the policyholder prior physical or psychological suffering to the signing of the insurance contract, the insurer would be exempt from the obligation to pay compensation.

Aplicado a los contratos seguros que contemplan como riesgo asegurado los tipos de invalidez citados anteriormente, para que existiera dolo se exige una relación entre la ocultación y la patología causante de la incapacidad.

Como ejemplo podemos citar la Sentencia de la Sección 2ª de la AP de Zaragoza de 3 May 2019, No.. 164/2019. En esta sentencia la Audiencia apreció dolo en la suscripción del cuestionario de salud por parte de la tomadora del seguro pues ocultó, al responder al cuestionario de salud, las patologías previas que padecía y que determinaron su incapacidad posterior. Thus, la Audiencia declaró la improcedencia del capital reclamado por esta en concepto de indemnización.

So good, el deber de declaración de las patologías sufridas por el tomador se ha configurado por la jurisprudencia más que un deber de declaración como un deber de contestación a lo preguntado por la aseguradora en el cuestionario. So that, si la aseguradora no presenta un cuestionario de salud o este es incompleto, impreciso y deja a la interpretación subjetiva de una de las partes determinados aspectos, debe asumir las consecuencias de esa presentación defectuosa; por lo que en estos casos no se consideraría un incumplimiento del deber de declaración del tomador sino un incumplimiento de las obligaciones de la aseguradora (especial importancia del art. 10 Ley de Contrato de Seguro y SSTS de 2 December 2014 rec. 982/2013, 4 December 2014 rec. 2269/2013, 3 June 2008 rec. 154/2001, of 11 May 2007 rec. 2056/2000 and 15 November 2007 rec. 5498/2000, inter).

What happens when, producido el siniestro, the declaration of medical disability is delayed and is no longer valid insurance that covered?

Plantemos aquí un supuesto práctico muy recurrente en la práctica y, es aquel por el que, contratado un seguro que contempla una incapacidad o invalidez, se produce el siniestro asegurado. So good, la determinación de invalidez se resuelve cuando la póliza ya no está en vigor. En estos casos muchas aseguradoras renuncian o se oponen al pago de la indemnización pactada.

Al respecto cabe señalar la Sentencia de la Sala Primera del Tribunal Supremo de 21 December 2016 and No.. resolution 736/2016 by which "lo decisivo es que cuando ocurre un accidente la póliza que asegura este riesgo esté vigente. Si es así se aplicará la cobertura, aunque la determinación de la invalidez a partir de la presentación del certificado médico de incapacidad se haya producido con posterioridad y la póliza no esté vigente. Lo importante es la relación de causalidad entre el accidente y sus secuelas; no la fecha en que se manifiesten éstas, ni mucho menos la de su constatación administrativa o médica. La cobertura se establece en función del riesgo asegurado, aunque proteja el daño indemnizable derivado de éste, que puede manifestarse con posterioridad al siniestro. Así lo afirma la jurisprudencia civil que distingue claramente entre el accidente, como riesgo asegurado, y el daño derivado del mismo: “la declaración de la invalidez, lejos de significar el hecho de la causación del daño o siniestro, es meramente una formalidad administrativa determinante, inter, de las consecuencias económicas en diversos aspectos del accidente, pero en modo alguno que pueda identificarse con éste”.

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