Contract trap · Insurance
Narrow benefit definitions
Illness claims barred for the first 14-30 days (pet/health), maternity/dental for 6-12 months, critical-illness benefits need a 14-30-day survival period, life policies exclude suicide and are contestable for two years; disability means 'any occupation' or loss of several activities of daily living, critical illness pays only listed diagnoses 'of specified severity', 'accident' excludes illness-caused falls, RU borrower cover pays only for «инвалидность I группы в результате несчастного случая»; cover starts at 00:00 the day after payment, ends at expiry mid-trip, applies only in listed territories, liability is 'claims-made' with a retroactive date.
- Severity
- Severe
- How often it turns up
- Common
- Holds up?
- Usually enforceable
- Clause phrases
- 24
What it looks like in a contract
Redline matches these phrases against your document verbatim. Drafters rarely invent new wording — they copy it, which is why the same sentences turn up across unrelated contracts.
In English-language contracts
- waiting period
- survival period of 14 days
- suicide within two years of the issue date
- contestability period
- any occupation for which you are reasonably suited by education, training or experience
- activities of daily living
- of specified severity
- carcinoma in situ is not covered
- solely and independently of any other cause
- cover starts at 00:01 on
- claims-made
- geographical limits
In Russian-language contracts
- период ожидания
- временная франшиза
- самоубийство в течение первых двух лет действия договора
- установление инвалидности I группы
- в результате несчастного случая
- критическое заболевание из перечня
- постоянная полная утрата трудоспособности
- не является страховым случаем инвалидность вследствие заболевания
- договор вступает в силу с 00 часов дня, следующего за днём уплаты страховой премии
- срок страхования
- территория страхования
- за пределами страны постоянного проживания
Check your own contract
Paste a clause, a page or the whole document. Nothing leaves your browser: the matching runs here, on this page, against the phrases above.
Why it bites
People buy just before a trip or treatment and are refused; a surgeon who can no longer operate but could teach gets nothing under 'any occupation'; carcinoma in situ is 'not cancer'; a borrower disabled by illness keeps paying the loan; an accident on the first night or a claim reported a week after expiry is uncovered — COVID-19 business-interruption claims turned on the exact wording of disease and access clauses.
Is it enforceable where you are
The same clause can be routine in one country and void in another. What follows is what the law says where you are — not advice on your particular contract.
In the UK, the Insurance Act 2015 and Consumer Insurance (Disclosure and Representations) Act 2012 restrict what an insurer may avoid; in the EU, the IDD and Directive 93/13 apply, and in the US, insurance is regulated state by state.
United States
Two-year contestability and suicide clauses statutory in most states; ACA limits group-health waiting periods to 90 days (PHSA §2708); ERISA plans reviewed deferentially unless state law bans discretionary clauses; claims-made forms standard for professional liability with mandatory extended-reporting offers; travel dates applied strictly.
- Cited
- ERISA
- PHSA §2708
European Union
CJEU C-96/14 Van Hove (2015): a 'total incapacity for work' definition in loan-repayment insurance escapes the unfairness test only if the consumer can evaluate its economic consequences; IDD product information document must state when and where cover applies; Germany VVG §161: suicide covered after three years.
- Cited
- C-96/14
- IDD
- Van Hove
- VVG §161
United Kingdom
ABI model definitions for critical illness with deviations flagged; FOS scrutinises 'any occupation' clarity; ICOBS requires clear start/end disclosure; FCA v Arch [2021] UKSC 1 construed disease and prevention-of-access clauses in favour of policyholders; CIDRA 2012 proportionate remedies for life insurers.
- Cited
- [2021] UKSC 1
- FCA v Arch
Russia
Upheld as risk definitions (ст. 942 ГК) when clear, ambiguity in the consumer's favour (ст. 431 ГК; п. 16 Пленума ВС № 19/2024); ст. 957 ГК — cover from premium payment unless the policy says otherwise, so «с 00:00 следующего дня» is lawful if stated; ст. 963 п. 3 — suicide covered after two years; территория использования admissible (п. 15 Пленума); ВЗР rules distinguish срок страхования from срок действия договора; Bank of Russia 2025 report criticises narrow triggers in borrower insurance.
- Cited
- Пленума ВС № 19/2024
- ст. 431 ГК
- ст. 942 ГК
- ст. 957 ГК
- ст. 963 п. 3
Where this has actually happened
Regulator actions, court rulings and the contracts they were fought over.
- CJEU Case C-96/14 Van Hove v CNP Assurances (23 April 2015)
- FCA v Arch Insurance (UK) Ltd & others [2021] UKSC 1 (15 January 2021): UK COVID-19 business-interruption test case decided largely for policyholders
- Russian Civil Code art. 963(3): suicide death benefit payable once the contract has run at least two years
What to do
In order, from the thing that takes a minute to the thing that takes a letter.
- Compare definitions, not premiums
- Prefer 'own occupation' and ADL-free definitions and read the illness list and severity thresholds
- Check 'When cover starts' / «Период ожидания» and 'Period of insurance' / «Срок действия договора и срок страхования» and 'Territory', buy a day early and extend before expiry
- For claims-made policies buy an extended reporting period on cancellation
- RU: check whether инвалидность II группы and illness-caused disability are covered
- Opaque definitions are challengeable (Van Hove) and ambiguity is construed against the insurer (ст. 431 ГК
- П. 16 Пленума ВС № 19/2024).
Traps that travel with it
Drafters who use one of these usually use several.