The Supreme Court grants, by means of a ruling, absolute disability insurance coverage to a former patient with leukemia, by accepting the diagnosis date as the date of the accident.
Life insurance, linked to a mortgage loan, includes absolute permanent disability as complementary coverage. According to one of the
clauses, for these purposes the date of the accident would coincide with the date of recognition of the disability by the competent body.
While the contract was still in force, the insured was discharged due to a common illness and was diagnosed with acute leukemia a few days later.
A year and a half later, when the insurance was no longer valid, he was declared in a situation of permanent disability due to a common disease, after the Opinion-Proposal of the Disability Assessment Team (EVI) that described the main clinical picture as acute leukemia.
The insured's claim was upheld in both instances and now the First Chamber dismisses the insurer's appeal, except in one aspect related to the order of the insurance beneficiaries.
Unlike what happens in the case of disability caused by an accident, in which the relevant date to determine the occurrence of the claim is the date of the accident, and not that of the subsequent declaration of disability, the Insurance Contract Law (LCS) does not give a definition of disability caused by a disease.
In the specific context of the Social Security legislation, the Social Security Chamber of the Supreme Court has interpreted that, as a general rule, it will be located on the date of the EVI opinion and that, by exception, the date of the causative event can be regressed to the actual moment in which the sequels are permanent and irreversible.
The Civil Chamber had already coordinated its jurisprudence in its day with that of the Social Chamber in terms of the date of the accident in the accident insurance and in this ruling of the Plenary the same coordination is carried out with respect to the date of the accident in the disability or permanent disability insurance. Consequently, it is presumed that they are concluded under the general rule and the exposed exceptions that, in addition, are consistent with the jurisprudential line of the First Chamber.
In this case, taking the date of the EVI opinion as the date of the claim, the claim would have occurred outside the period of validity of the policy if the general rule is applied. But the doctors dating before described reveal that the disease causing permanent disability -leukemia- is revealed as permanent and irreversible as a first diagnosis, which occurs when the policy is still in force, for which reason the exception that allows considering the date of the sinister the diagnosis of the disease and the insurance coverage is declared. The clause of the policy that fixed the date of the accident at the time determined by the competent body is limiting the rights of the insured, therefore, by not meeting the requirements of art. 3 LCS (it is not highlighted in the policy nor is it expressly stated), result not available.
mortgage cancellation
Lastly, as it is an insurance linked to a mortgage loan in which the first designated beneficiary was the lending bank, it is established that, charged to the insured sum, the outstanding balance of the loan must first be delivered to the bank and the remainder, if any, to the insured. At this point, the insurer's appeal is estimated.
