Mountaineer wins compensation case against large insurance company

The Delikti.bg team successfully defended the interests of a client in a case related to a refusal to pay insurance compensation by a large insurance company. The case concerns an accident suffered during mountain pass, covered by insurance "Tourist accident". 

The client of Delikti.bg, within the insurance period (the period during which the concluded insurance contract is valid), suffered a severe injury during a mountain hike, resulting in a fracture of the ankle of the right leg. For the insured event that occurred, expenses were incurred for medications and an operation, during which two malleolar screws of 44 and 46 mm were placed. The total cost of the expenses was 2479 leva. 

After due notification to the insurer, the payment of compensation was refused on the grounds that certain documents – a hotel invoice, lift tickets or other transport, proving the trip – were not presented. According to the insurance policy (the document that certifies the conclusion of a contract between the insurer and the insured), these are documents that, according to the insurer, prove that the accident occurred during an activity of the type „short-term recreation or tourism“. This was a condition stipulated in the insurance contract. 

The essence of the dispute 

The Delikti.bg team challenged the grounds for the insurer's refusal to pay compensation. An important argument of our lawyers and jurists was that the requirement to present a reservation or ticket is not relevant for the emergence of the right to compensation in the event of an accident that occurred within the scope of the covered risks. The Delikti.bg client undertook a one-day mountain hike, during which he did not need to be transported by lift or other means of transport. Therefore, he did not need to purchase a ticket, he did not have a document from a hotel/lodge reservation to present to the insurance company. 

The special conditions of the insurance contract requiring these documents are categorically unfair within the meaning of the Consumer Protection Act (CPA), as they place the consumer in a disadvantageous position and limit his rights. Moreover, the reservation, card or ticket can in no way serve to establish the basis of the client's claim, much less to establish the relevant event and the amount of damages. 

Of particular interest were the costs of medical devices used in the client’s treatment (the two screws inserted during the surgery). The insurer argued that these costs fell into the category of excluded risks, citing certain clauses in the contract. In particular, they stated that „medical devices during surgical interventions“ were not covered. 

The insurance contract contained inaccuracies and ambiguities regarding medical definitions, which in turn created uncertainty for the client, who could hardly predict what expenses were covered.  

More about sports accident compensation here.

The court's decision 

The court accepted the argument of Delikti.bg's lawyers that the mountain trek, carried out within one day, constitutes an activity covered by insurance and that the lack of a ticket or reservation cannot serve as a ground for refusal. Furthermore, the court determined the clauses in the contract that set such requirements as unfair and therefore invalid. 

Regarding medical expenses, during the course of the case we clarified that the contractual clauses in question are unclear, misleading and put the insured at a disadvantage. Additionally, Delikti.bg was able to prove that according to the general terms of the contract, the costs of products necessary for traumatic injuries resulting from an accident – as is the case with our client – should be covered. 

The special clause in our client's contract that excluded medical device costs was deemed unequal, as it significantly restricted consumer rights contrary to the spirit of the law. 

The insurer was ordered to pay the full amount of the medical expenses claimed, as well as legal fees incurred by our client. Despite the court's decision in favor of our client, the case is not yet over because the insurer has the right to appeal.

This case is indicative of the importance of professional legal protection in a dispute with insurers. If you are faced with a refusal to pay insurance compensation, do not hesitate to contact the Delikti.bg team. We will protect your rights and fight for a fair solution.