It is worth looking at the small print: even if a clause lists several examples, it may not be legally valid.
When it comes to insurance clauses, consumers must be able to understand when exactly insurance cover is excluded. It is therefore worth taking a look at the details. A very generally worded clause in a foreign travel health insurance policy regarding an exclusion “in the case of a previously known medical condition” was, in the view of the Federal Court of Justice (BGH) in Karlsruhe, non-transparent – and therefore ineffective. (Ref.: IV ZR 129/23)
According to the BGH, it is not only important that a clause is formulated in such a way that an average insured person can understand it. In the case of so-called exclusion clauses, the disadvantages and burdens must be made clear – as far as possible – in such a way that the person can see the extent of the insurance that still exists afterwards.
In its ruling, the BGH criticizes the fact that in the specific case it is not clearly defined which medical condition leads to exclusion from benefits. There is only a non-exhaustive list of examples – for example, if a person has been hospitalized in the last twelve months or has been diagnosed as “incurable” and/or “chronic.”
However, this does not allow insured persons to “identify with sufficient certainty which other “conditions” should be covered by the exclusion of benefits and which should not.” The examples only partially refer to serious illnesses. There are also no uniform requirements for the duration of the illness. Insured persons are therefore unable to identify which other illnesses, which are not covered by any of the examples, also mean that insurance cover no longer applies.
This specific case concerned general insurance terms and conditions. The provider had concluded a group insurance contract with a bank, including international travel health insurance for the benefit of credit card holders.
