Ihere is often an abyss between what the insured expects from his contract and what the insurer has put in it: the insurance mediator, Arnaud Chneiweiss, expressed his regret on Monday, August 29, in Paris, during a a press conference to present its report for the year 2021.
To convince members of the Association national insurance journalists, in front of whom he spoke, of the character “too restrictive” of certain definitions used by insurers, he launched a small quiz.
“Do the following four situations constitute an accident, covered by the insurer? »he asked, before recalling that the” accident “ is usually defined as “any bodily injury, unintentional on the part of the insured, resulting exclusively and directly from the sudden and unforeseeable action of an external cause”.
- The insured slipped on a puddle of oil on a sidewalk.
- The insured fell down the stairs of his house due to feeling unwell.
- The insured injured his knee during sports training, by making a false movement during a rotation.
- The insured injured himself while trying to grab a refrigerator that was tipping over while he was carrying it.
Many journalists, although supposedly knowledgeable, were wrong. Here are the answers :
- Yes, it is an accident: the oil puddle, an external cause, occupies a “abnormal position” on the pavement. Insurance must therefore come into play.
- No, it is not an accident: the malaise is an internal and not an external cause… Insurance should therefore not come into play.
- No, it is not an accident, the torsion of the knee not constituting an external cause.
- Yes, it was an accident: the moving refrigerator, an external cause, presented an abnormal dynamic without which the disaster would not have occurred.
The insurance mediator also returned to the “fuzzy exclusion clauses”which are still included in insurance policies, even though they are illegal.
He invited his public to say whether, in the following situation, the exclusion clause should apply or not: Mr. X adheres to a group insurance contract which must pay him benefits in the event of incapacity for work. Following a nervous breakdown (without hospitalisation), during which he stopped working, he asked to be compensated. The insurer refuses. He opposes the clause of his contract which excludes “Nervous depression, psychiatric disorders and psychic disorders”. Is he right ?
No, replied Mr. Chneiweiss. The insurance code indeed says that the exclusion clauses must be “formal and limited”that is to say, according to case law, “clear, unambiguous, and not subject to interpretation”. Terms ” nervous breakdown “ are certainly clear, but as they are followed by a fuzzy notion, “mental ailments”which is supposed to be banned, the “clause set” must be invalidated.
This was judged recently the Court of Cassation regarding a clause excluding “disabilities resulting from low back pain, sciatica (…) and other back pain ». The phrase “and other back pain”although attached to specific terms, resulted in the insurer (CNP) invalidating the entire clause, deemed unenforceable against the insured.
The mediator therefore asks that imprecise formulas such as the“non-compliance with the rules of the art”the “lack of maintenance” or the “negligence of the insured” join the cohort of banned expressions such as the “good father” Where them “sexually transmitted diseases”.