When you have an accident, it is best to contact your insurer as soon as possible. After all, you have insurance to cover the costs, so then it is best to make use of it.
But what if the claim is not covered by the insurance policy? It often happens that the insurer lists all kinds of reasons and situations in the insurance contract for which they will not intervene. These are the policy's grounds for exclusion. When one of these grounds for exclusion is present, the insurance company is not required to intervene and you will therefore have to pay the damages yourself.
Therefore, the question that arises here is whether the insurer made a correct decision in whether to grant its intervention or not?
Does the exclusion ground apply?
If you believe that the exclusion ground does not apply based on the written terms in the policy, you should consider to what extent the clause was written with sufficient clarity and precision.
If a clause is unclear, Article 23, §2 of the Insurance Law should be consulted. This article says that in case of doubt about the meaning of a clause, the most favourable interpretation for the policyholder/insured person applies. If the policyholder and insured are not the same person, then the most favourable interpretation applies to the insured.
In case of (persistent) vagueness about the insurance contract, the common intention of the contract parties must always be ascertained, rather than adhering to the literal meaning of the words (Art. 5.64 Civil Code). Accordingly, this intention of the parties to be ascertained is that which existed at the time the insurance contract was concluded.
If the wording of the clause is open to multiple interpretations, it must be interpreted in the sense in which the clause can have any effect and which corresponds best to the content of the contract (Art. 5.65, 1°-2° Civil Code).
If the rules of interpretation above still do not provide a solution, then the insurance contract will be interpreted to the detriment of whoever has stipulated it, and to the benefit of whoever has bound himself (Art. 5.66 Civil Code).
Case law has already explicitly ruled on exclusion clauses that the insurer is the one who has stipulated the clause, while the insured is the one who has bound himself. In case of doubt, the exclusion clause should therefore be interpreted in favour of the insured.
However, the insurer's obligation to draft clauses in clear and precise terms does not mean that the wording of existing terms has to be changed each time to take into account technological developments, nor does it mean that it has to specify whether or not each particular hypothesis is covered (Cass. 12 January 2024, C.23.0238.F/1).
In the above-mentioned judgment, the Belgian Court of Cassation ruled that when the contract is concluded with a consumer, in case of doubt, the interpretation most favourable to the consumer applies in any case (in accordance with art. VI.37, §2, 1st paragraph WER).
The Court of Cassation went even further, stating that the rule of most favourable interpretation applies to the policyholder in any case, regardless of whether or not he is a consumer (Art. 23 Insurance Law).
In addition, the assessment on the clarity and precision of a clause will be based on the point of view of a normal and average sensible policyholder who is not a specialised legal expert (Cass. 9 April 1992, Arr.Cass. 1991-92, 769).
Conclusion
Thus, the text of a clause must be sufficiently clear, to an average policyholder/insured without prior legal knowledge, in order for the insurer to make use of the exclusion ground in the insurance contract.
When there is any doubt about the interpretation of a clause, it must be strictly interpreted. So, there should not be any free interpretation. In case of persistent doubt about the meaning of a clause, it should be interpreted in the sense most favourable to the insured.
In other words, in the absence of clarity, the ground for exclusion will not be applied and the insurer will therefore have to provide cover.
Contact Wanted Law
Are you in doubt whether the exclusion ground applies or are you considering initiating proceedings? Feel free to contact one of our Wanted Lawyers so that we can advise and assist you personally.