Just as insurers, when signing the insurance policy, undertake to pay the claims covered by it, insurance companies may also be exonerated from paying compensation for various causes that are set out in the policies themselves or in the law.
Let us review, even briefly, what these causes are.
THE EXCLUSIONS: In the words of Dr. J. Efrén Ossa G. (General Theory of Insurance – The Contract, p. 469), exclusions are Facts or circumstances that, even if they are the origin of the damaging event or its effect, do not oblige the insurer to be responsible.”
These exclusions, to which we refer, can be of a legal or contractual nature, depending on who imposes or agrees to them. Let's see them.
- Legal exclusions: As their name suggests, these are those that are imposed by law and many of them can be found in our Commercial Code through its various provisions. Don Efrén Ossa groups them into a large classification, as follows: I) "Intentional provocation of the loss event." which he considers totally uninsurable, since it leaves the occurrence of the loss event in the hands of the contracting party, insured or beneficiary. Examples in our legislation: (a) in relation to accident insurance, suicide, (art. 1060), (b) in relation to damage insurance, those caused by fraud or gross negligence of the insured or of a person for whom he is civilly liable, (c) the transformation of the nature of the insured item or the application of the item to a use other than that declared, (art. 1001), and (d) the prohibition of the insurer to “become responsible for the acts of the insured (art. 1003); II) “Gross negligence as the cause of the loss.” This type of negligence of the insured is also uninsurable and was already mentioned in point I) above and is expressly cited in art. 1001 of the Commercial Code; III) “Catastrophic risks in damage insurance.” Although they are normally expressly included in the policies; wars, acts of a foreign enemy, insurrection, rebellion, acts intended to influence through terrorism or violence and strikes, among others, art. 1060 of the Commercial Code, within insurance against accidents, expressly mentions the lack of coverage of “war or riot”;IV) “Inherent vice.” This is the subject of the oft-cited article 1001 of our code, when it establishes that “The insurer is not responsible in any case for damages or breakdowns caused directly by inherent vices or by the nature of the insured items…”.
- Contractual exclusions: This type of exclusions, also called conventional, are those that insurers insert in their policies as a warning to the insured about those risks that are not covered or, if they are, will not be covered by the insurance if they are preceded or accompanied or are the cause of any of these exclusions. These exclusions are of great importance for the insured, since their understanding depends on knowing whether their claim will be covered by the policy. Regarding the above, the Insurance Law establishes in numeral 2 of art. 143, the following: “Exclusions and limitations must be included in bold characters within the policy." The reason for this is unnecessary to explain. The so-called “fine print” in policies is not supported.
To make an exhaustive account in this capsule of all the exclusions that an insurer can include in the policies is a task that would take a lot of time and space to enumerate. The reader also knows that the purpose of this publication is not to make an insurance treatise but rather brief notes on specific topics.
In order not to deviate from this tradition, it is enough for the moment to point out that exclusions can be general in nature for all coverages, or special for additional coverages that can be contracted through an express agreement and that vary depending on the type of coverage or insurance in question.
Although it is important for the insured to know the coverage that his policy grants him, it is also extremely important that he is aware of those that are not to avoid unpleasant surprises when filing his claim.
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