Guia para reclamar un seguro de vida

seguro de vida

In this guide we review the procedure to successfully claim the fulfillment of a life insurance contract the insurer

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NATURE OF LIFE INSURANCE CONTRACTS AND REGULATION FUNDAMENTAL

As the law 50/1980, of 8 October, Insurance Contract (onwards, LCS), in his article 1, "The insurance contract is one for which the insurer undertakes, by charging a premium and if the event occurs whose risk is hedged to indemnify, within agreed limits, the damage to the insured or to meet capital, income or other benefits agreed. " It is a definition to which we referred in our entry on unfair terms in insurance contracts, of 18/09/2017.

The contrato de seguro de vida, It is a specific type of insurance contract persons. De acuerdo con el artículo 80 LCS, insurance contracts people are those who are used to hedge risks "That may affect the existence, integrity, or health of individuals. "

That group insurance contracts on people is regulated under Title III LCS, and comprises, in addition to the life insurance contract, accident insurance, disease, health care, Death and dependence.

Within that Title III, Articles 83 a 99 regulating the life insurance contracts. The article itself 83 LCS indicates that the life insurance contract is one for which "The insurer undertakes to satisfy the beneficiary capital, una renta u otras prestaciones convenidas, in case of death or survival of the insured, o de ambos eventos conjuntamente.”

Depending on what the insured risk, we can distinguish the following types of life insurance contracts:

1. Death insurance: It is covering the risk of the insured person dies.

2. Survivorship insurance: covering the risk of the insured person survives beyond a certain date.

3. mixed insurance: It is covering both the risk of death, as the survival of the insured person.

4. Disability Insurance: charged by the risk that the insured person put at a total disability, absolute or serious disability, according to what is agreed in the contract.

PERSONAL ITEMS IN LIFE INSURANCE CONTRACTS

Knowing the nature of the life insurance contract and types that can be found, it is necessary to refer to the different people who may be involved in an insurance contract. In general, in addition to the insurance company, persons involved life insurance can take the place of the insurance taker, del asegurado, or the beneficiary. It is also possible that several or all roles coincide in the same person.

Taker insurance who he is contracted with the insurance company life insurance in particular. It is also, therefore, the obligation to pay insurance premiums.

the insured is the person who holds the risk to be hedged with insurance. In insurance covering the risk of death of the insured, when the policyholder is a person other than the insured is necessary that it also consents to the conclusion of the insurance contract. On the other hand, the insured may never be disabled or under 14 years old, and if, being older, is less, the consent of their legal representatives will be necessary.

The beneficiary of the insurance It is who will receive the benefit of the insurance company if the risk is verified. It shall be appointed by the insurance taker, you can do both in the policy and later, or even testament, can also revoke any beneficiary, provided that he had not given up that power. If, performing risk, there was no beneficiary declared, compensation or income to pay the insurance company will enter the patrimony of the policyholder, to be distributed under the hereditary rule if it has died. Also, compensation is divided among all beneficiaries equally, where there are several, but if they are heirs will distribute according to the hereditary quota they have been assigned.

Consequences of non-payment of the insurance premium

We must make special reference also to the consequences of non-payment of the premiums for the same. To this article refers 15 LCS, which provides for the following two assumptions made differentiated:

1. If payment of the first premium lack, or single premium, insurance contract:

Then the insurer is released from the obligation to perform the service agreed (pay compensation, or income, for example), and can therefore by executive demand payment of the same, how to proceed to terminate the contract.

To terminate the contract in this case, it is sufficient that the insurer withdraws from the contract, without requiring there is a court statement to respect (SSTS 17 January 1986 and 4 April 1990).

2. If payment of a lack of the following raw:

Coverage will be suspended (the insurer being released from its obligation) one month after the day on which the deadline to pay that premium. Also, if six months elapse without the insurer claim the premium payment, it shall terminate the insurance contract.

This implies that, if the loss occurs during that month, the insurance company compensation due will continue to be required to pay, or to provide the service to which it had committed (STS 5 March 2004, among many). Also, in the case that the premium is paid by direct debit, there are court rulings that establish the opening day of the "month of grace" on the date the insurer will notify the policyholder of the insurance had not been able to charge premium.

Also, both one and the other course, it must be emphasized that "If between the date of the contract and the occurrence of the facts irrefutable notice from the insurer, for having terminated the contract for non-payment of premium, however, pending collection it, It understood that the insurer was to force the contract " (STS 17 October 1991).

In any case, must remember that, if the contract has not been terminated or canceled in previous cases (either because the insurance company will not proceed with it in the first case, or that require the payment of the premium in the second), the back cover to take effect at midnight of the day the policyholder paid the overdue premium.

KEY DEADLINES IN LIFE INSURANCE

Regarding the claim of the provision agreed in the insurance contract the insurer, There are two deadlines are essential, and that must be mastered and know completely, because they directly affect the obligation of the insurer to perform the agreed service (deliver capital, rent or any other provision), and, therefore, also to the right of the beneficiary to receive the benefit. These key deadlines are as follows:

1.- Deadlines to notify the insurance company of the accident production

First, it is essential to note that the term has the taker insurance, the insured, or the beneficiary to notify the insurance company that has taken the risk against which had been the insurance (Sinister).

As already we indicated, such loss can consist death of the insured, or survival, or has entered into a situation of disability.

Specifically, Article 16 LCS explicitly that "The insurance policyholder or the insured or the beneficiary should I inform the insurer of the occurrence of the incident within a maximum period of seven days have known, unless it is set in a broader term policy. Failure to comply, the insurer may claim damages caused by the lack of declaration. This effect will not occur if it is proved that the insurer has been informed of the incident by other means. "

That way, the fundamental consequence of violating this period is that the insurer may claim damages suffered as a result of the delay. Generally, They will refer to the aggravation of the loss during the period in which it is not claimed.

The problem is that, If already the deadline is very short duration, It is perfectly possible, for example, in case of death of the insured, the beneficiary ignore that the deceased person had life insurance. The solution to this situation of ignorance passes request a certificate of insurance contracts covering death, in which you can check whether the person on whom the certificate is requested had hired a safe and which entity.

However, the application for that certificate, It presented by the model 790 by post, face or telematics, you can not make until they have not passed 15 working days from death of the insured person. This places the beneficiary or the insurance taker virtually forced failure within 7 we noted earlier days.

Fortunately, Article 16 LCS continues to indicate that "this effect will not occur if it is proved that the insurer has been informed of the incident by other means. The insurance policyholder or the insured must, also, give the insurer all kinds of information about the circumstances and consequences of the accident. In case of violation of this duty, the loss of the right to compensation will only occur in the course that had crowded severe pain or guilt. "

So, in any case, If the lack of notification within 7 days due to a reason other than negligent or deliberate, you need not worry. Simply request the certificate as soon as possible, keep proof of submission, and notify the insurer the claim as soon as we receive it.

On the other hand, it is necessary to differentiate the duty to inform the production of the claim within the prescribed period of 7 days, of the duty to provide insurance for any information about the circumstances and consequences of the accident, because while the former refers to communicate the very fact that the risk consists verified, the second extends the complementary circumstances of the operative event of the insured damage. That distinction is crucial because, as indicated by the Supreme Court in its judgment 264/2016, of 20 April 2016, "It is possible to complete that first obligation, then neglecting the duties of supplementary information to the insurer."

In that case we can find an example of what can happen if, in addition to notifying the loss, not reported to the insurer all circumstances that may arise from simultaneous or subsequent manner and relating to the same:

University General Hospital Consortium of Valencia had sued Zurich Spain S.A. not meet the payment of compensation to the hospital itself due to D. Alexander as a liability. En febrero de 2007 It was formulated by D. Alexander application for liability, but the hospital only made two communications to the insurer, Attach 19 June 2008, to notify the production of the accident, and over the 27 July 2010, to notify the sentence definitively he condemned the hospital to pay compensation for liability.

On these facts, the insurance company refused to meet any compensation, understanding that the Consortium General Hospital Universitario de Valencia had breached its obligation to provide information about the circumstances of the accident. The Supreme Court, As you can imagine, Zurich ruled in favor of Spain S.A., and he indicated that the hospital had committed serious disregard of its obligations and had caused serious injury to the insurer, to which it has been prevented any possibility of defense in proceedings that were substantiated.

2. Limitation period to claim the insurance company fulfilling the contract

Last, the limitation period of the action to demand compliance with the insurance contract is the most important among all other, because it will be the deadline to determine whether, existing insurance contract, the insurer will or obligation to pay us the agreed compensation.
Regarding this period, Article 23 LCS specifically provides that "Actions arising from the insurance contract shall prescribe within two years if it comes to damage insurance and five if insurance is people."
However, it does not mean having to bring previous corresponding demand in that time span, Well being a limitation period and no expiration, always it is possible to interrupt the period by an extrajudicial claim of remaining reliable record (for example, with burofax content certificate and acknowledgment).

LIFE INSURANCE CONTRACTS LINKED TO OTHER PRODUCTS

and usually, especially, during the housing bubble and the indiscriminate use of mortgages, Life insurance has "offered" to linked with other financial products from credit nature, such as home equity loans, advances in public grants or credit cards.

We say that it has "offered" because, actually, are credit institutions who have been demanding their customers that formalizasen an insurance contract as a requirement to access any financial product. And though, in theory, It was perfectly possible that the client celebrase said life insurance contract with any entity, It has been usual, and it still being, the financial institution itself offered to the customer celebrate the life insurance contract with an entity linked to it.

So that companies pursued was twofold: on the one hand, They managed to secure the eventual capital of the mortgage in case of death or disability of the borrower; por otro, They are increasing the volume of hiring in your insurance company linked.

Well, It has happened after, in many cases, that the client had contracted life insurance with the insurance company linked to the financial institution that offered the mortgage loan, finally held, He died or left in a situation of disability. Then, such as life insurance contract whose conclusion had forced the bank covered the amount of the loan if it died or became incapacitated debtor the, customers requesting the insurance company to pay the loan, or to the bank itself to claim the payment to that. Course, nor the insurer paid, neither the bank demanded payment of compensation to the insurer. Quite the contrary, receipts were still going on repayments to the heirs of the deceased borrower, or the borrower himself who had been incapacitated.

Fortunately, there are multiple sentences, in these situations, They have been condemning insurance companies to pay the amount of loans that had covered. In that sense, is paradigmatic judgment of the Supreme Court, Civil Court Ollie # 1110/2001, of 30 November, cuando indica que "In the practice of mortgage loans granted by the banks it is conditional on borrowers conclude a life insurance or repayment guarantee significantly strengthens; plus, if the borrower arranges insurance company to freely choose, the Bank has offered to manage a company that is linked bargaining or societariamente ".

However, necessary be cautious enough to, If claim is made against the insurer, not ask that it give compensation to the deceased debtor or borrower who has been incapacitated. This would entail the dismissal of the complaint for lack of active legitimacy (judgment of the Audiencia Provincial de Cartagena Ollie # 164/2017, of 13 June), because all that corresponds to that borrower, as policyholder and debtor, this is condemns request the insurer to pay the beneficiary, which it is the bank.

CONTROVERSY health questionnaire

In most claims to insurers to fulfill the contract life insurance held appears an argument used by those trying to discharge its obligation to pay compensation.

That argument is to argue that, when the survey was conducted health, the insurance policyholder to the insurer did not disclose the existence of the disease, in the end, caused the death or disability of the insured.

That "Duty declaration of risk" appears enshrined in Article 10 LCS provides that "The insurance taker has a duty, antes de la conclusión del contrato, de declarar al asegurador, de acuerdo con el cuestionario que éste le someta, all circumstances known to him that may influence the assessment of the risk. "

However, of the same article are two important limitations to this duty: the first, which it is not exactly a duty to declare the risk, but rather a no duty to answer truthfully the questions that are made by the insurance company; the second, that there is no duty to report circumstances that the insurance taker himself to the time unaware of conclusion of the contract.

Regarding the first limitation, we can cite the judgment of the Audiencia Provincial de Zaragoza, of 07/07/2017, he understood that the insurance taker did not have to bear the consequences of the insurer would have made the test so negligent health, no questions regarding minimally relevant health data.

Regarding the second limitation, the judgment of the Provincial Court of Cartagena de 09/05/2017, ordered the insurer to pay compensation to the heirs of a policyholder who, anticipating his death for health reasons (but without knowing what was wrong), He entered into a contract of insurance to prevent welfare of their own.

SOME JUDGMENTS LIFE INSURANCE

Among many, We can not end this legal guide without reference to the following court rulings:

Supreme Court Decision, First Chamber, 08/11/2007:

“El artículo 10, instead of conceiving a general and abstract terms the limits of duty of the policyholder to declare all circumstances known to him that may influence the risk assessment, He has limited this duty limiting it to the answer to the questionnaire submitted by the insurer. it appears well, not a duty spontaneous or independent of the policyholder, but a duty to respond to a questionnaire that has its precedent in Swiss law ".

Supreme Court Decision, First Chamber, 10/09/2015:

"They stopped paying the second division of the second year, which expired on 19 August 2009. Within six months from the non-payment of the second raw, without the insurer had claimed payment, the insurance contract was terminated automatically and legal effect of the provision itself, without it being necessary to urge the resolution by either party. Thus, the 19 February 2010 the insurance contract was terminated, and when he later died Sr. Fausto, this risk was no longer covered by life insurance have become extinct. "

Supreme Court Decision, First Chamber, of 16/03/2016:

"It is inferred that the insurance company previously fulfilled his duty to submit to the insured completing a health questionnaire, Properly said, without possibility, therefore, that it could fulfill its duty to respond to events or circumstances that may be relevant to the assessment of risk "

Judgment of the Court of First Instance and Instruction Ollie # 01 Negreira, 14/07/2016:

"There has been credited consent of the plaintiffs in the underwriting of insurance called credit amortization of death and invalidity claim must be upheld by the lack of such consent alleged in the complaint, the result of restitution of the amount paid and amounted to the sum of 11.053,95 euros, as apparent from the doc. N.º 1 demand and No. 2 reply. "

Supreme Court Decision, First Chamber, 05/07/2017:

“(…)given the terms in which the statement is written by health insurance company, it is inconceivable that because tomadora not manifest itself in 2009 the background of possible psychosis suffering from late 2003 was hiding relevant health data for risk assessment, because he was not asked […], It must be the insurer that supports the imprecision of the questionnaire -Declaration health and the consequence of such imprecision that did not come to know the state of health of the insured at the time of signing the policy, sin que pueda apreciarse incumplimiento doloso por el tomador del seguro del deber de declaración del riesgo que permita liberar a la aseguradora del pago de la prestación reclamada con base en los arts. 10 and 89 LCS”

THE IMPORTANCE OF AN ATTORNEY IN LIFE INSURANCE

Los contratos de seguro de vida son productos complejos para una persona no especializada en ellos, porque incorporan multitud de cláusulas conteniendo condiciones generales, particulares y especiales, que incluso pueden aparecer como contradictorias entre sí. That is why so, desde aquí, recomendamos especialmente contar con la figura de un abogado especialista en seguros para asegurar que su reclamación sea útil y fructífera. Nos gustaría destacar los siguientes extremos:

1. La reclamación de un seguro de vida sin la intervención profesional de un abogado puede implicar que se faciliten a la compañía de seguros documentos o información que pueden ser perjudiciales para los intereses del asegurado.

2. Toda reclamación de un seguro exige establecer una estrategia extrajudicial, o pre-procesal, y judicial, o procesal, con carácter previo a la ejecución de cualquier actuación. El abogado especialista en seguros no sólo conoce la ley, sino también qué argumentos suelen utilizar las aseguradoras y cuáles son sus puntos débiles.

3. Also, conviene que antes de iniciar la reclamación se efectúe un informe o análisis de viabilidad de la reclamación, analizando globalmente las condiciones del contrato, el cuestionario de salud realizado, y las comunicaciones efectuadas con la entidad aseguradora, para determinar si la reclamación puede tener buen fin o no.

4. Generally, la documentación necesaria para estudiar la viabilidad de la reclamación del seguro de vida es la siguiente: a) Declaración de fallecimiento o incapacidad d la persona asegurada; b) Copia de la póliza de seguro, incluyendo condiciones particulares, especiales y generales; c) Recibos de pago de las primas del seguro; d) Cuestionario de salud realizado; and) Cualquier contacto o comunicación que haya existido con la compañía de seguros.

Ultimately, la Ley del Contrato de Seguro contiene especificidades y cuestiones no pacíficas en la jurisprudencia que hacen imprescindible la contratación de un abogado especializado en seguros de vida.

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