How do you define yourself “accident” in an insurance contract?

Seguro de Accidentes

The definition of “accident” agreed by the parties to the insurance contract prevails over that of the art. 100 LCS

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Article 100 of la Law of Insurance Contracts defines the concept of accident without prejudice to the delimitation of the risk that the parties made in the contract.

2nd Section of the Provincial Court of Lleida, in Case 19 September 2019 (Res. No. 424/2019)  He resolved in favor of the insured in a dispute over an accident. The insurance company refused to pay compensation to the insured impeditive days starting from the concept of accident specified in art. 100 Law of Insurance Contracts. He concluded the hearing that the allegations of the insurance were based on an erroneous premise to the stand solely on the concept of Article, so they must first attend rise to the concept agreed by the parties to the contract and, Secondarily to the articles of the LCS.

Fact background,,es,Juan Alberto and Paulina filed suit against FTA,,es,Asset Securitization Fund,,es,requesting the declaration of nullity for abusive of the floor and ceiling clauses contained in the novation contract of the mortgage loan of,,es,with the corresponding refund of amounts unduly collected,,es,The Securitization Fund Management Company,,es,Beech,,es,acting on behalf of FTA, he responded to said claim alleging that he lacked passive legitimacy since the entity had no legal personality and that it constituted only a private and open fund and that therefore the passive legitimization corresponded to BBVA as successor of Catalunya Banc that was the Company fund constituent,,es

The 4 May 2014 Mr. Alfonso he signed with a bank loan agreement.

Directly linked to this and the same date, He signed with the insurer SEGURCAIXA ADESLAS INSURANCE AND REINSURANCE one insurance contract. The bank was the main beneficiary irrevocable by the 100% of debit and / or referral fee loan.

The insurance contract guaranteed status temporary disability. In the policy itself was defined the temporary disability as the situation "irreversible, expected transient and reversible insured, either due to illness or accident, requiring the medical care and / or treatment and the same, on prescription, involves the interruption of the development of the corresponding economic or funcionarial activity.”

Among the exclusions of temporary disability benefit, Clause 2.3.5) He contemplated as such "any process or pathology whose sole or main symptom is pain, has no direct accidental or traumatic origin and its cause is not demonstrable medical diagnostic tests ".

The day 23 October 2015, for conducting a physical education class, and, insurance policy still valid, Mr. Alfonso suffered a work accident.

The lesion consisted of an acute traumatic lumbar detente type and so was found by the orthopedist in his report 21 February 2016.

This injury caused temporary disability in Sr. Alfonso from 3 November 2015.

Primera Instancia

The 28 February 2018 el Juzgado de Primera Instancia nº 8 Lleida gave judgment estimating the lawsuit filed by D. Alfonso.

He ordered the defendant to pay to the plaintiff the amount of 5.073,40 euros for compensation from the coverage temporary disability included in the insurance contract. All this plus interest Article 20 LCS.

Provincial Court

seguro de accidentesThe insurer defendant appealed. He did not contest the accident suffered by Mr. Alfonso: He refused it got to an accident in the terms demanded by the art. 100 Law of Insurance Contracts (LCS).

This is because the necessary civil matters was that it was a bodily injury resulting from a cause sudden external, alien to the intention of the insured. It must have originated from a different cause of organic disease. They were excluded organic lesions that may occur suddenly, but by internal origin were.

Therefore the insurance alluded to the erroneous assessment of the evidence that it incurred the first instance judgment. No record in the medical documentation accidental or traumatic origin of the ailment that caused sick leave. But instead if there was a preexisting degenerative disease.

He alleged that the appellant had not established the traumatic course, between the hypothetical contusion and low medical eleven days were far. Also, no record of that hypothetical contusion was the cause of sick leave.

Therefore, the appellant claimed that a clear accidental or traumatic origin could not be established, whose evidence in any case, it was up to the actor. And it is therefore illogical that the statement claimed that there was no evidence of lumbar degeneration.

The appellant had sought the application of the grounds for excluding paragraph 2.3.5) of the insurance policy.

The 19 September 2019 2nd Section of the Provincial Court of Lleida gave judgment dismissing the appeal of SegurCaixa.

He considered the audience that appellant's arguments were based on an erroneous premise to the stand solely on the accident concept art. 100 LCS, as well as focusing the debate on the lack of evidence on the decisive traumatic injury incapacity.

The art. 100 LCS collected a definition of accident but, as the provision itself determined, without prejudice to the delimitation of the risk that the parties made in the contract”. So that, First it was necessary to go I agreed between the parties.

About, the respondent referred to the introduction by the applicant of facts that were not controversial at first. Well, He never questioned that bring down medical cause of the accident.

The Court noted that the defendant did not challenge at first instance the existence of the accident or the cause of sick leave. So it was not permissible in the raised causation is called into question between each other.

It was true that the medical report revealed the degenerative disease of the spine. But as it noted in the contested decision, Estimator Sr. Calixto said that this degenerative disease was normal and usual in a person's age and profession of Sr. Alfonso.

In over thirty years of professional activity (from 1984), Mr. Alfonso had not suffered any sick leave by back pain, nor any other pathology related to this. Nor it consisted in the Clinical History forwarded any medical care or treatment prior to the accident that could be related to that pathology.

The Juzgadora Instance did not state that there was no evidence of lumbar degeneration of Mr. Alfonso, but there was no evidence to determine that the actor suffered pain before the accident or reflect a situation of severe degeneration or higher than normal.

I could not be labeled as unreasonable, absurd or irrational conclusion of sitting by the Juzgadora Instance rejecting a degenerative origin of the lesion and consider instead, the incapacity for work was caused by traumatic cause.

The exclusion clause invoking the appellant did not apply for not giving accurate estimates to the effect.

It was not simply that he had established the existence of the accident,  but, ultimately, tests performed to Prove the evaluative criterion of Juzgadora Instance. And specifically, to the conclusion that if it had been established the traumatic pathology, and the causal link between it and the temporary disability of the insured.

The Court dismissed the appeal and upheld the first instance judgment.

Conclusion

To set the term accident for the purposes of an insurance contract, it must be first agreed to by the parties and, in the absence of definition will attend the art. 100 LCS.

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