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Old 20.01.2020, 15:52
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Rejection of accident insurance coverage after a year

I had an accident in July 2018, and the accident insurance (through my employer) agreed to cover the incident. During this time, they have continuously paid for my doctor visits, medication, physiotherapy, chiropractic, etc with no problem.

This week however, they sent me a letter saying that they have reevaluated my case by external doctors, and concluded that they should have stopped the coverage 3 months after the incident (Oct. 2018). They also mention that they will not reclaim the paid bills, but will not pay the outstanding ones (those before they notified me) or any new ones.

Assuming that I am covered by the accident insurance, I have not followed the protocol of my health insurance over this time (I had a pharmed plan with Assura). For example, I didn't get the medication from Assura designated pharmacies, I went to a specialist without a referral from a family doctor and also visited an Osteopath.

Now here is my question:
Can the accident insurance stop paying the bills retrospectively? Is there a clause in the law that allows them to do so?
Do I have any grounds in asking them to pay the previous bills that are not covered by my health insurance?
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Old 20.01.2020, 15:58
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Re: Rejection of accident insurance coverage after a year

Sounds a bit odd. What are their grounds for rejection?
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Old 20.01.2020, 16:03
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Re: Rejection of accident insurance coverage after a year

Did you change jobs or were made unemployed during that time? If they "stopped the coverage", it would sort of make sense if you moved to a new company which used a different insurer for its employees, although maybe they continue ongoing care for an individual after they've left the company?
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Old 20.01.2020, 17:11
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Re: Rejection of accident insurance coverage after a year

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Sounds a bit odd. What are their grounds for rejection?
They say the present pain is not anymore because of the accident, and the accident effect should have gone away in 3 months.

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Did you change jobs or were made unemployed during that time?
Yes, I did but as far as I know you cannot carry a previous accident to a new accident insurer. The accident insurer at the time of incident should continue paying as long as it is justified.

Right now my question is not why they have done this, but whether they can stop paying retrospectively!
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Old 20.01.2020, 17:42
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Re: Rejection of accident insurance coverage after a year

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They say the present pain is not anymore because of the accident, and the accident effect should have gone away in 3 months.


Yes, I did but as far as I know you cannot carry a previous accident to a new accident insurer. The accident insurer at the time of incident should continue paying as long as it is justified.

Right now my question is not why they have done this, but whether they can stop paying retrospectively!
Normal procedure would be, the insurer send you to see a "Vertrauensarzt" (fiduciary doctor). After that such a decision can be made. And usually is

They can not decide on your current state without a doctor having checked you out.
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Old 20.01.2020, 17:46
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Re: Rejection of accident insurance coverage after a year

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Right now my question is not why they have done this, but whether they can stop paying retrospectively!
You need to start by looking at the policy and go from there. Do you have a copy of the policy you can check?
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Old 20.01.2020, 18:18
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Re: Rejection of accident insurance coverage after a year

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You need to start by looking at the policy and go from there. Do you have a copy of the policy you can check?
No, mandatory accidents insurance is regulated by law and not by contracts or insurance policies.

Back to OP's problem: retroactive refusal of insurance cover is only permissible in a few cases. I suspect foul play on the part of the insurance company. Did they give you a deadline to appeal their decision?
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Old 20.01.2020, 18:27
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Re: Rejection of accident insurance coverage after a year

Do you have legal insurance? If so, use it!

Tom
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Old 20.01.2020, 21:09
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Re: Rejection of accident insurance coverage after a year

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No, mandatory accidents insurance is regulated by law and not by contracts or insurance policies.
Except in certain circumstances it can be voided.
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Old 21.01.2020, 11:56
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Re: Rejection of accident insurance coverage after a year

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retroactive refusal of insurance cover is only permissible in a few cases.
Thanks!
Could you please provide a pointer to the law that says this, if possible?
And yes, I have until 10.02.2020 to object to this.
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Old 21.01.2020, 12:11
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Re: Rejection of accident insurance coverage after a year

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No, mandatory accidents insurance is regulated by law and not by contracts or insurance policies.

Back to OP's problem: retroactive refusal of insurance cover is only permissible in a few cases. I suspect foul play on the part of the insurance company. Did they give you a deadline to appeal their decision?

Insurance companies are equipped with lawyers and experts to support there version. My case was rejected after a year where insurance company decided that I have to pay back all the cost including a knee operation. I had to involve Rechtschutz lawyers and they negotiated a deal where insurance company. My advice is to get a lawyer if the cost is too high.
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Old 20.01.2020, 17:53
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Re: Rejection of accident insurance coverage after a year

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They say the present pain is not anymore because of the accident, and the accident effect should have gone away in 3 months.


Yes, I did but as far as I know you cannot carry a previous accident to a new accident insurer. The accident insurer at the time of incident should continue paying as long as it is justified.

Right now my question is not why they have done this, but whether they can stop paying retrospectively!
I would definitely fight for them to pay all treatment that happened before they informed you of the fact that they are no longer willing to pay.
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