Collection of insurance compensation: claim, court, legal assistance

Collecting insurance compensation is a pressing issue that requires special attention. You were involved in a traffic accident, but the insurance company did not pay you the insurance compensation, or paid you, but not in full. There is no need to worry, since the collection of insurance compensation is one of the areas of activity of our law office, located in the center of Yekaterinburg.

Grounds for insurance compensation

The basis for payment of insurance compensation is the occurrence of an insured event. What is an insured event? According to the law, an insured event is an event upon the occurrence of which the insurer is obliged to make a monetary payment to a certain person. For example, a person has insured his liability in the event of a traffic accident. An accident has occurred, the person is at fault, and the insurance company must pay a certain amount of money to the victim.

In order for everything to be paid under the insurance, it is also necessary to follow a certain procedure, i.e. collect documents, notify the insurance company about the occurrence of an insured event, etc.

PLEASE NOTE : when concluding an insurance contract, as a rule, insurance companies indicate such insured events (events), the occurrence of which is practically zero, as grounds for paying insurance to a person. For example, with health insurance, the insurance company may indicate that payment will be made if an insured event occurs in which a brick falls on the insured person's head.

That is, if you insure your property, health, etc., carefully read the insurance contract, focusing on the events in which you will receive an insurance payment. Obviously, in certain places of residence there is no point in insuring your property against a volcanic eruption or earthquake, and if the insurance company says that it does not insure against other cases, then there is no need to enter into such an agreement.

USEFUL: watch the VIDEO on the topic

Lawsuit: types, differences

To understand the procedure, let's consider the situation in detail.

When purchasing a car, you take out a mandatory MTPL policy. The motorist thinks that there will be no need to pay for the damage themselves if he becomes the culprit of the accident. Insurers, having paid the amounts to the injured party, try to compensate the costs at the expense of the culprit. Claims can be filed in two ways:

by way of subrogation: the victim’s insurance company demands that the culprit pay the difference between the limit on compulsory motor liability insurance (400,000 rubles) and the actual costs of repairs. The limitation period of 3 years is counted from the moment of the accident;
through a regressive claim: the own insurance company tries to reimburse the victim’s expenses incurred. Presented in cases recognized as non-insurance (absence of a compulsory motor liability insurance policy, driver’s license, etc.). The same statute of limitations begins from the moment the company makes payments.

It is important to determine what requirements are presented in order to properly build a line of defense. In most cases, it is possible to change the original amount claimed.

Registration of insurance compensation

To receive an insurance payment, the insured person must confirm that a particular insured event has occurred. Let's consider the algorithm of actions using the example of a road accident.

So, you got into an accident:

Assess the situation and the need to call the traffic police officers, since in certain cases it is possible to draw up documents without calling the police, namely, if only vehicles were injured in the accident, only 2 vehicles were involved in the accident, the liability of the participants in the accident is insured, the damage caused to the vehicle in the accident does not cause disagreements and does not exceed 100 thousand rubles.
If the police were not called, fill out the accident notification form (to be completed by both drivers) in 2 copies, which must be sent to the insurers within 5 working days from the date of the accident. Also take photos and videos at the scene of the accident, recording, among other things, the nature of the damage to the vehicle;
Contact the police if you filled out documents without calling the traffic police to draw up a report on an administrative offense and other documents in connection with the accident.
The insurer may require the vehicle to be presented for inspection and examination.

When contacting an insurance company for insurance payment, the victim:

notifies the insurer of the occurrence of an insured event;
submits an application to the insurer for insurance compensation to be paid to him;
attaches documents to the application: a copy of the passport, documents on the bank details of the victim, a notification of an accident, a copy of the protocol on the administrative offense, and other documents drawn up by the employees of the accident.

Additional protection options

If the notification of an accident or the traffic police certificate contains a clause about the mutual fault of the drivers, this point will be taken into account when considering the claim. It is not allowed to satisfy recourse claims in full from only one of the car owners if the documents indicate mutual guilt. In this case, the court must determine the degree of guilt of each of the participants in the accident, after which the amount of the claim will be proportionally reduced.

The law also allows for a number of other options for protecting the rights of citizens:

after a judicial act is issued, you can file a petition for installment payments - the court will establish a payment schedule taking into account the financial situation of the defendant;
it is possible to grant a deferment on collected payments - the court may give several months until the first payment;
After sending documents to the FSSP service, forced deduction from earnings can be carried out in an amount not exceeding 50% of monthly income.

If you promptly seek the help of a professional lawyer, you can expect the claim to be rejected due to the statute of limitations expired, or for a significant reduction in the amount of the amount recovered. Another option for solving the problem may be to conclude a settlement agreement, under the terms of which the amount of recovery may be significantly reduced.

Deadline for payment of insurance compensation

The general period for payment of compensation in connection with an accident is 10 days, in some cases 30 days. The period is calculated from the date the insurer receives the application for insurance payment. If damage is caused while transporting passengers by metro, the insurer is obliged to pay compensation no later than 30 days.

If harm is caused to third parties by an organization that operates hazardous production facilities and which has insured its liability for damage to health and property of third parties, then in the event of an accident at such a facility and damage to third parties, the insurer pays insurance payments within the time limits specified in agreement In particular, to the rules of liability insurance in the case under consideration, an appendix is a standard insurance contract, and it states that the insurer must make a payment within 10 working days when it receives an application from the insured with a court decision attached to it that the insured is obliged to compensate damage from an accident at the relevant facility, and an act of technical investigation of the accident.

The payment terms can be established by law and contract; it all depends on whether the insurance is voluntary or compulsory. In each situation, it is necessary to study the contract, as well as regulations.

Pre-trial collection of insurance compensation

It is not entirely correct to talk about pre-trial collection of insurance, since in this case collection still implies forcing a person to pay money, and they can be legally forced only through bailiffs who work on the basis of writs of execution issued under judicial acts.

In this case, we can talk about the voluntary satisfaction of the claims of the insured person by the insurance company, when claims and statements are sent to the insurer for payment to be made.

In a claim or statement, it is advisable to make references to the rules of law that govern the insurer’s obligation to make payments and liability for violation of payment deadlines. The insurer, seeing a well-drafted claim or application, will approach its consideration more seriously and responsibly.

You can also negotiate with the insurer on the issue of payment, explaining what your further actions will be if payment is not made voluntarily, which consists of going to court, filing claims not only for the collection of insurance compensation, but also various penalties, fines, etc. .d.

Grounds for refusal of a pre-trial claim to an insurance company under compulsory motor liability insurance

There are only a few main reasons why insurance companies deny a claim.

The appeal was sent by a person who is not a victim and formally has nothing to do with the insurance business. The proper level of authority is not confirmed by the power of attorney.
The claim is not accompanied by documents that are evidence of the victim’s claims. For example, an assessment report prepared by an independent expert.
There is no information about the bank account to which the refund can be paid.

A negative response to the claim is sent to the policyholder by mail.

Collection of insurance compensation through court in Yekaterinburg

There is no point in wasting time and nerves on negotiations and verbal disputes with the insurance company on issues of compensation for insurance damage. The only effective way to get the money you are owed is to go to court to demand insurance compensation.

After the court decision enters into legal force, you will be issued a writ of execution, which you can send either to the Federal Bailiff Service to initiate enforcement proceedings, or, preferably, to the bank serving the insurance company, which will transfer the insurance compensation to your account within three days .

Also, with our help, you can recover the loss of the marketable value of the car from the person at fault for the accident or the insurance company, if the insurance company believes that you do not have the right to it and refuses to reimburse insurance payments.

Please note that disputes with insurance companies regarding the collection of insurance compensation are subject to the federal law “On the Protection of Consumer Rights.” This gives you the right not to pay the state fee, as well as to file a claim at your place of residence. Moreover, this law will allow you to recover a fairly significant fine from the insurance company, as well as compensation for moral damage.

At the same time, when filing a claim in court for compensation of insurance payments, you can recover from the insurance company either the full amount of expenses for the services of a representative, or a significant part of it.

How to justify the amount of the claim?

Keep in mind that the amount of the claim against the insurance company may not be limited to compensation for material damage. But for this it is necessary to provide a competent justification for all components of your requirement.

Material damage: the amount of payments under this article should be determined based on the results of the examination. If the court sided with you, the insurance company will pay compensation in full, and will also compensate you for the costs of conducting an independent examination and using the services of a lawyer.

Moral damage: this type of compensation is more difficult to obtain, since it is not easy to prove moral suffering. However, we advise you to visit a psychologist and obtain the appropriate certificate, as well as undergo treatment at a clinic in case of physical injury. Keep in mind that litigation can also be classified as moral damages that must be compensated to the plaintiff.

In addition, in court you can insist on the payment of penalties, penalties and fines in accordance with the terms of the insurance contract, as well as legislative acts. A competent lawyer will help you correctly calculate the claims, collect the necessary evidence and draw up a statement of claim, which will contribute to a positive decision by the judicial authority.

Sources:

Peculiarities of consideration of disputes under compulsory insurance contracts

Form and content of the statement of claim

Time limits for consideration of a claim in court

Claim for recovery of insurance compensation

If the insurer voluntarily does not pay the payment, then it is necessary to prepare and file a claim in court. A claim for recovery of the amount of insurance compensation is filed according to the general rules specified in Art. 131, 132 Code of Civil Procedure of the Russian Federation.

What you should pay attention to when preparing a claim:

It is necessary to indicate when the plaintiff or other person entered into an insurance contract with the defendant and what cases are provided for in the said contract for payment to the insured person. It is also necessary to indicate when and in what amounts the plaintiff paid money for insurance.
It should be reflected that a situation has occurred that is an insured event; indicate when and under what circumstances the insured event occurred.
Next, you should indicate what actions were taken by the plaintiff to receive insurance payment from the insurance company, and what actions were taken by the insurance company in response to the application of the insured person.
If the insurer is late in payment, also file a demand for interest on the use of someone else’s money.
It is also important to refer to specific rules of law confirming the legality of the claims made by the plaintiff.

When preparing a claim, it is necessary to refer to documents confirming the arguments and circumstances of the plaintiff; copies of the relevant documents must be attached to the claim.

Attention: our lawyers have participated in the reimbursement of loan insurance, insurance reimbursement for road accidents, as well as in other similar cases, which gives you confidence in our experience in solving your problem.

Health insurance: compensation disputes

In Russia, life and health insurance is not as widespread as in European countries; often, some large companies themselves insure their employees or insurance is purchased when taking out a loan.

The main features of life and health insurance are established in the Civil Code of the Russian Federation and in the Law “On the organization of insurance business in the Russian Federation”. The specified regulatory legal acts establish that non-property (personal) insurance can be established in relation to the life and health of a person, as well as in relation to his survival to a certain age.

As a general rule, the insured person has the right to receive compensation upon the occurrence of an insured event, but in accordance with Art. 934 of the Civil Code of the Russian Federation, in addition to the insured person, the beneficiary can receive payment if he is specified in the contract. In the event of a person's death, the heirs of the deceased have the right to receive payment.

Actions of a person upon the occurrence of an insured event

To receive insurance payment, you must carry out a series of sequential actions.

First, you need to inform the insurance company about the occurrence of an insured event and prepare an application for receiving insurance payment. As a rule, the insurance company itself provides forms or samples of this application. The application must be accompanied by an identification document of the insured person (beneficiary), documents confirming the right to receive insurance compensation and a document confirming the time of the occurrence of the insured event. This document may vary depending on the type of event that occurred and the type of insurance contract.

Such documents may include:

Conclusion or certificate from the attending physician
Certificate of disability
Conclusion of the commission on an industrial accident
Certificate from a medical institution, extract from a medical record, certificate from an emergency room (copies of documents must be certified by a medical institution)
Other documents

All documents must be in Russian (if there are documents drawn up on the territory of a foreign state, a notarized translation must be prepared).

When submitting an application to the insurance company, you must ask for a stamp from the employee accepting the application, with the company’s seal and the number of the incoming document.

The deadlines for filing an application after the occurrence of an insured event and the deadlines for paying insurance compensation are determined by the insurance contract or insurance rules.

When can an insurance company refuse to pay?

The application and documents were submitted later than the period stipulated by the insurance contract (rules)
Some documents are missing
Incorrect information provided
The insured event does not fall under the terms of the contract
The terms of the contract were violated by the policyholder (for example, failure to pay the insurance premium on time deprives the right to receive insurance compensation)

Litigation with an insurance company under life and health insurance contracts

Unfortunately, cases of refusal to pay by an insurance company are not rare; their number has recently increased. Based on the analysis of judicial practice, we have prepared some recommendations.

To substantiate his claims and arguments in the statement of claim, the plaintiff is recommended to provide the court with evidence of proper and timely application to the defendant for payment of insurance compensation. Based on the analysis of judicial practice, they can be the following documents: application/appeal for payment of insurance compensation/security; statement about the occurrence of an insured event; application for the submission of additional documents; a claim requesting an insurance payment; a court decision that has entered into legal force, containing information about the existence of a cause-and-effect relationship between incorrectly performed medical procedures and the harm to the plaintiff’s health; discharge summaries and other medical documents, as well as an audio recording and transcript of a telephone conversation between the plaintiff and the defendant’s representative, in which he reported the occurrence of an insured event; documents confirming the plaintiff’s contact with the defendant by email; an extract from the cellular operator company, which confirms the fact that the plaintiff contacted the defendant’s hotline (for example, Appeal rulings of the Moscow City Court dated June 26, 2019 in case No. 33-27300/2019, dated May 22, 2019 in case No. 33-17916/ 2019).

Before filing a claim in court for payment of insurance compensation, you should pay attention to the validity period of the personal insurance contract and the date of occurrence of the insured event. If the insured event (for example, the determination of disability for the plaintiff) did not occur during the validity period of the insurance contract, but after the expiration of this period, there is a high probability that the court will make a decision in favor of the defendant (for example, Appeal rulings of the Moscow City Court dated 05/07/2019 in case No. 33 -19469/2019, dated 04/04/2019 in case No. 33-14476/2019).

The plaintiff needs to know that the burden of proving the circumstances for this category of disputes is distributed between the parties as follows. The plaintiff (the policyholder) has the obligation to prove the existence of an insurance contract with the defendant, as well as the fact of the occurrence of an insured event provided for by the said contract. The insurer objecting to the payment of insurance compensation is obliged to prove the circumstances with which the law or contract connects the possibility of exemption from payment of compensation, or to challenge the insured's arguments about the occurrence of an insured event (for example, the Appeal ruling of the Moscow City Court dated December 12, 2018 in case No. 33-54639 /2018).

In the event that payment of insurance compensation is refused due to failure to provide information about the presence of diseases ( for example, the Appeal ruling of the Moscow City Court dated January 16, 2019 in case No. 33-1108/2019)

, about which the insured person was aware, about which he was treated or received medical advice, immediately preceding the start date of insurance, it should be indicated that the law provides for other special legal consequences of failure to inform the insurer of information about circumstances that are significant for determining the likelihood of an insured event occurring than refusal to pay insurance compensation - Art.
944 of the Civil Code of the Russian Federation ( for example, the Appeal ruling of the Moscow City Court dated December 8, 2016 in case No. 33-49083/2016).
In particular, if, after concluding an insurance contract, it is established that the policyholder has provided the insurer with knowingly false information, then the insurer has the right to demand that the contract be declared invalid and the consequences provided for in paragraph 2 of Art. 179 of the Civil Code of the Russian Federation (clause 3 of Article 944 of the Civil Code of the Russian Federation). If there is a legally valid insurance contract, there are no grounds provided by law for refusal to pay insurance compensation in such a situation (for example, the Appeal ruling of the Moscow City Court dated February 12, 2016 in case No. 33-3057/2016).

The law does not directly provide for the possibility of releasing the insurer from insurance liability in the event of loss of ability to work with the establishment of disability of the insured person due to the very fact that the insurer is unaware of the presence of any disease in the insured (Articles 963, 964 of the Civil Code of the Russian Federation)
(for example, the Appeal Determination of the Moscow City Court dated December 8, 2016 in case No. 33-49083/2016).
According to the Supreme Court of the Russian Federation, if the insurer refused to pay insurance compensation on the basis that the plaintiff, when concluding an insurance contract, concealed the presence of a disease for which a disability group was subsequently established, it is necessary to establish whether the insurance contract provides for refusal to pay insurance compensation in this case
(for example, Determination of the Judicial Collegium for Civil Cases of the Supreme Court of the Russian Federation dated December 4, 2018 No. 67-KG18-18).
In judicial practice, there are examples of cases where the courts, taking into account the content of the insurance contract and the insurance rules, recognize as legitimate the insurer’s refusal to pay insurance compensation due to the fact that, when concluding the insurance contract, the insured person provided the insurer with unreliable (knowingly false) information regarding the state of his health (for example , Appeal rulings of the Moscow City Court dated September 20, 2019 in case No. 33-41778/2019, dated April 24, 2019 in case No. 33-13476/2019).

Thus, in one of the cases, the court found that the insurance contract directly provided for its invalidity from the moment of conclusion due to the presence of diseases in the insured person, which, as the plaintiff indicated in the application when concluding the contract, he does not suffer from
(Appeal ruling of the Moscow City Court dated 12.12.2018 in case No. 33-54639/2018).
This point of view is supported in paragraph 10 of the Review of the practice of courts considering disputes arising from relations on voluntary personal insurance related to the provision of a consumer loan, approved. The Presidium of the Supreme Court of the Russian Federation on June 05, 2019, where it was explained that the communication of knowingly false information about the health status of the insured when concluding a voluntary personal insurance agreement is grounds for refusal to pay insurance compensation, as well as for declaring such an agreement invalid.

By virtue of the provisions of paragraph 2 of Art. 945 of the Civil Code of the Russian Federation, the insurer has the right, when concluding a personal insurance contract, to conduct an examination of the insured person to assess the actual state of his health. If the insurer did not properly exercise its right to assess the insurance risk, did not request medical documentation from the plaintiff, did not offer to undergo a medical examination, and did not show the due degree of good faith and diligence when concluding the insurance contract, then responsibility for improper assessment of the degree of insurance risk cannot be assigned on the insured person or beneficiary (for example, Appeal rulings of the Moscow City Court dated 08/06/2018 in case No. 33-27366/2018, dated 12/08/2016 in case No. 33-49083/2016).

In one of the cases, the court, deciding in favor of the defendant, came to the conclusion that the absence of data from a medical examination of the policyholder at the initiative of the insurer does not relieve the policyholder from the obligation to report reliable data known to him about the state of his health (for example, the Appeal ruling of the Moscow City Court dated 01/16/2019 in case No. 33-1108/2019).

The guilt of the insured in the occurrence of an insurance event is the most frequently used basis for the insurer’s refusal to fulfill obligations (Article 963 of the Civil Code of the Russian Federation). The most common grounds for unilateral refusal, not provided for by current legislation, are: 1) the commission of a crime by the insured that is in a direct cause-and-effect relationship with an event that has the characteristics of an insured event (for example, Determination of the Moscow City Court dated June 20, 2017 No. 4G-6829 /2017);

2) consumption of alcohol, toxic substances, as well as narcotic, potent and psychotropic substances by the insured
(for example, Appeal rulings of the Moscow City Court dated April 10, 2019 in case No. 33-13809/2019, dated November 12, 2018 in case No. 33-49888/2018 ).
However, the presence of the insured person in a state of alcoholic intoxication is not an independent basis for refusal to pay insurance compensation provided for by civil legislation (Articles 961, 963, 964 of the Civil Code of the Russian Federation).
In addition, the absence of a connection between the state of intoxication and the occurrence of an insured event is the basis for recognizing the refusal to pay insurance compensation as inconsistent with current legislation (for example, the Appeal ruling of the Moscow City Court dated April 10, 2019 in case No. 33-13809/2019).
Despite this, in judicial practice there are examples of cases where the courts recognize as legitimate the refusal of the insurer to pay insurance compensation if the insured event occurred while the insured person was intoxicated or as a result of an illness caused by the use of alcoholic beverages, and at the same time in accordance with the insurance contract or the rules (conditions) of insurance, such cases are not recognized as insurance (for example, the Decision of the Second Cassation Court of General Jurisdiction dated 03.03.2020 in case No. 88-5661/2020, the Appeal decision of the Moscow City Court dated 04.10.2019 in case No. 33-16488/2019 ).

When making a claim for the collection of a fine for an unreasonable delay by the insurer in paying insurance compensation, it should be borne in mind that the legislator, when determining the basis for collecting a fine, proceeded from the criterion of the insurer’s bad faith and the unreasonableness of the refusal to satisfy the claims of the insured person (for example, the Ruling of the Supreme Court of the Russian Federation dated April 20, 2015 No. 16-KG14-40).

A fine is a measure of liability for violation by the insurer of the obligation to timely pay insurance compensation (
for example, Determination of the Moscow City Court dated April 10, 2015 No. 4g/6-2876/15).
Thus, if the defendant paid the amount of insurance compensation within the time limits established by law, but in a smaller amount, and the dispute is exclusively about the amount of insurance compensation, then such actions cannot be regarded as a refusal by the defendant to satisfy the plaintiff’s claims.
Accordingly, there are no grounds for collecting a fine in the absence of evidence of an unreasonable delay in payment of the insurance amount by the defendant (for example, the Appeal ruling of the Moscow City Court dated December 10, 2013 in case No. 11-40842/2013).
If a demand is made to collect a fine from the defendant under clause 6 of Art. 13 of the Law of the Russian Federation dated 02/07/1992 No. 2300-1, the plaintiff must prove that the insurer was contacted with an application for payment of insurance compensation by an appropriate person, who was unreasonably refused to satisfy the application. Such a person may be the policyholder (beneficiary) under the personal insurance contract, as well as a person who has the proper authority by virtue of Art. 182 of the Civil Code of the Russian Federation.

If the application was not made by the policyholder himself, but by a person who was not the policyholder (beneficiary), and also did not have a notarized copy of the document confirming the relationship with the insured person, and a notarized power of attorney to receive insurance payments, then it is impossible to collect a fine according to the specified norm (Decision of the Supreme Court of the Russian Federation dated May 19, 2015 No. 18-КГ15-38).

From the contents of paragraph 6 of Art.
13 of the Law of the Russian Federation dated 02/07/1992 No. 2300-1 it follows that the law does not make the award of a fine dependent on the policyholder’s request indicating a certain amount to the insurer (Appeal ruling of the Moscow City Court dated 02/18/2016 in case No. 33-***/2016 ).
Need a trial lawyer? To assess the prospects for resolving a dispute and calculate the cost of services, call us at 8 (495) 223-48-91 or submit a request.

Order