An important question when it comes to the benefits of personal accident insurance is how an accident is defined. The general definition of an accident is an unforeseen, sudden, external event that happens unintentionally, resulting in damage or injury of the body.
While this definition is quite clunky, it is important to understand. Accidents and their causes vary dramatically, but a personal accident insurance claim is decided by the facts of the situation leading up to the injury. The definition also makes clear that you must not cause the accident on purpose and it must not be caused by an internal influence (more on this in a moment). So if you are fouled badly while playing football and your leg remains stiff for a long time, you could be covered by accident insurance. The same applies if you help your friend move and you pull a muscle or drop a heavy cabinet on your foot.
Most insurance policies also cover accidents that you cause yourself through increased exertion or movement – i.e. without sudden external influence. This includes, for example, if you trip over a tree root while jogging in the morning and dislocate a joint, or if you tear tendons or ligaments when you fall off your bike. Even if the damage occurs later, it is still considered an accident – for example, if you fall into a crevice while climbing and get frostbite. Be aware that the consequences of the accident must be permanent (more on this in the section: "What conditions must be met for the insurance to pay out?)
As explained above, an accident in the sense of accident insurance is defined as a bodily injury caused directly by an external event. An illness is therefore not an accident and not covered by personal accident insurance. In addition to illnesses (such as diabetes or joint diseases), congenital disorders (such as abnormal spinal alignment) are also not included in the coverage. This also applies if you faint and you fall, because fainting is usually caused organically (for example by epilepsy or a stroke). Of course there are also marginal cases. That is why the insurance company always looks at the individual case.
It is a common misconception that all unintentionally caused injuries are covered by personal accident insurance. The scope of benefits varies from provider to provider.
Most accident insurance policies do not cover accidents caused by mental disorders or disturbed consciousness. This includes accidents caused by a stroke, alcohol, drugs or medication. For example, if you drive your car into a crash barrier when drunk and seriously injure yourself, you are yourself responsible for the accident and the accident insurance does not pay out. Accidents caused by radiation, infections or poisoning are also usually excluded. Damage to intervertebral discs or meniscus are also considered by many insurance companies as ordinary bodily ‘wear and tear’ and are not accepted as accidents. And even though it is probably obvious, it’s worth mentioning that if you compete in a car or motorcycle race and have an accident, you have to bear the consequences of the accident yourself.
Normal sports accidents are usually covered by your personal accident insurance. However, there are exceptions for risky sports. If, for example, you are a passionate motorcycle racer or enjoy paragliding or hang-gliding, you need separate coverage.
For the insurance to pay out, your health must be permanently impaired for at least three years. Experts call this disability, meaning that your state of health will not improve. You can read more about this in this glossary article. Temporary consequences of an accident, such as a broken leg, are not covered. It is also necessary that the impairment of your physical or mental ability results from the accident.