Life insurance and complement premium exoneration

seguro exoneracion pago

 

To what point supplement insurance premium payment exemption produces its effects?

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La indemnización por un Supplement Insurance premium payment exemption debe hacerse desde el momento de producción del siniestro y no desde la declaración de tal situación por el INSS.

The Provincial Court of Pontevedra, section 1, in Case 3 septiembre de 2019 and No 465/2019 He resolved in favor of the policyholder in a case on a Supplement Insurance premium payment exemption. The tomadora concluded a seguro de vida and Supplement Insurance premium payment exemption. Incident occurred consistently in the declaration of disability the same. The insurer set as triggering event the time the Disability Assessment Team issued an opinion. But the Court concluded that the time from which should deploy its effects supplementary insurance was in production loss (specifically, detecting a disease) and not when a report was issued by the Administration.

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 7 May 2004, Ms.. Cándida signed with the company MAPFRE VIDA S.A., a policy of seguro de vida an Supplement Insurance premium payment exemption absolute and permanent disability.

The effective date of the policy began on 15 May 2004 and ending on 15 May 2019.

The guaranteed capital was 21.421,45 euros.

The main life insurance guaranteed receipt of benefits for both the case of survival and of death.

For his part, with complementary insurance premium payment exemption for permanent total disability, the policyholder would be exempt from payment of premiums both life insurance and supplementary insurance itself.

In January 2010 Ms.. Candida was diagnosed with breast carcinoma.

Como consecuencia, the 28 January 2010 He was discharged with a diagnosis of "malignant neoplasm female breast".

The 12 November 2010 by resolution of the INSS was declared in situation invalidez permanente the degree of absolute for all work.

Later, the 1 October 2013 he told Mrs.. Cándida no afecta de ningún grado de permanent disability por mejoría.

Ms.. Cándida filed administrative complaint was estimated by Resolution 12 December 2013. It was recognized in a situation of total permanent disability for usual occupation due to common illnesses.

That decision was appealed to the social jurisdiction.

The 26 January 2015, INSS he recognized, again, Dña. Cándida no incursa en ningún grado de permanent disability. The objective consequences appreciated revealed an impairment practically nil with the possibility of work activities.

The 28 April 2015 the Labor Court No. 1 Pontevedra resolved that Ms.. Candida was still in situation incapacidad permanente absoluta for any profession or trade for common illness.

The INSS appealed the earlier judgment.

Finally, the 14 June 2016 the Social Chamber of the High Court of Galicia confirmed the judgment.

The 3 May 2016, Ms.. Candide asked the insurance company pay compensation. Given the refusal, She filed a complaint.

Primera Instancia

The 12 December 2018 el Juzgado de Primera Instancia nº 1 Lalin gave judgment for estimated the lawsuit against MAPFRE VIDA SA. condemning the plaintiff to reimburse the premiums paid since January 2010 the policy of life insurance and supplemental insurance fee waiver. All with payment of legal and default interest of art. 20 Law of Insurance Contract (LCS).

The Juzgadora instance based its decision on the declaration of permanent total disability derived from breast carcinoma and depressive direct consequence of the disease.

Therefore, from January 2010 (time of diagnosis) was taking place because of exemption from payment of premiums, corresponding, therefore, the return of their amounts.

The fact that Ms.. Cándida not communicate his statement of disability, in order for an exemption from payment by the insurer, fit to understand by ignorance had on the insurance clauses.

Provincial Court

Against the first instance judgment, the insurer defendant appealed, claiming that, under the previous judgment of the Labor Court of Pontevedra, was severe reactive depression which led to the declaration of failure of the plaintiff. Said depression had not been diagnosed until the report of the Mental Health Unit 18 October 2013. And it was in the opinion of the Disability Assessment Team (EVI) of 17 December 2014 when it first appeared diagnosed with a mixed adjustment disorder.

The appellant added that, “in the event that the contingency that the invalidity is derived by common disease (no accident), the rule, the lack of agreement, It is going to rule on mandatory Social Security benefits that sets the triggering event on the date of the opinion of the EVI, except when the consequences appear consolidated with incapacitating nature at an earlier date ". No constaba probado que la depresión de hubiera producido simultáneamente al diagnóstico del cáncer. La propia Juzgadora de instancia reconocía que fue la depresión reactiva grave la que condujo a la declaración de incapacidad absoluta de la actora. Thus, la sentencia debía ser corregida en el sentido de que, el hecho causante (declaración de incapacidad permanente absoluta) debía entenderse producido desde la fecha del dictamen del EVI (17-12-2014). La exoneración del pago de las primas procedería desde el 17-12-2014 the, en el peor de los casos desde la fecha de la resolución del INSS que concedió a la actora la incapacidad permanente absoluta (12-11-2010). La asegurada que la actora tenía pleno conocimiento del clausulado del seguro. No comunicó su situación hasta el mes de octubre de 2015, manteniéndose vigente, por tal conducta, la cobertura de fallecimiento que obligaba al pago de las primas.

The 3 September 2019, Section 1 of the Provincial Court of Pontevedra delivered its judgment No 465/2019 desestimando el seguro de Mapfre.

La cuestión controvertida era el momento de operatividad de la cobertura del seguro complementario.

Al respecto consideró acertada la decisión de la Juez “a quo” of situar el siniestro en el momento de diagnóstico de la enfermedad de carcinoma de mama. Y ello porque este diagnóstico fue determinante para el subsiguiente reconocimiento por el INSS de una situación de degree of permanent disability in absolute for all work. Dicha situación de incapacidad se mantuvo en las resoluciones judiciales del orden jurisdiccional social de los años 2015 and 2016.

La sentencia del Juzgado de los Social de Pontevedra ya determinó que, a las secuelas propias de la enfermedad, se debía añadir un cuadro de depresión grave. Al punto de considerarse esa patología depresiva como un factor reafirmante y coadyuvante de la situación de incapacidad.

Se debía considerar la depresión reactiva emergente desde el primer momento del conocimiento por la paciente de su enfermedad de base (carcinoma de mama).

La testigo Dña. Andrea, amiga de la actora, señaló que esta tuvo depresión desde “el minuto cero”. He added that, a partir del diagnostico, la actora nunca estuvo en condiciones de trabajar; el tratamiento le afectó al corazón, no podía caminar ni respirar.

Fueron aportados informes de la Unidad de Saludo Mental del SERGAS correspondientes a los años 2010, 2011, 2012 and 2013 que corroboraban la necesidad de terapia desde el diagnóstico por la actora.

Therefore, la Audiencia consideró oportuno situar en el mes de enero 2010 la fecha de acaecimiento del riesgo objeto de cobertura por el seguro complementario de exoneración de pagos de primas de seguros. Esto conllevaba la procedencia de la condena de la aseguradora demandada a la restitución del importe de las primas satisfechas por la actora desde el mes de enero de 2010.

La devolución de las primas abonadas debía ser por su importe total,   pues se garantizaba la exoneración del pago de las primas de los seguros, sin excepción de importe alguno.

Conclusion

El momento a partir del cual opera el seguro complementario de exoneración de primas es el de producción del siniestro, pues éste es el que va a desencadenar la declaración de la situación asegurada (incapacidad o fallecimiento).

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