Dismissal of claim under disability income insurance due to lack of evidence of illness-related incapacity to work

Facts

Parties and contractual relationship: The appellant ([A.] ) is managing director of [C. AG] and was insured with the respondent ([B. AG] ) via his company against loss of earnings due to illness. The insurance was based on a collective disability income insurance policy, which, as an additional insurance to social health insurance, is subject to the Insurance Contract Act (IPA).

Subject of dispute: The appellant claimed disability benefits for the period from 1 April to 10 July 2022, after the insurer had already paid benefits for February and March 2022. The respondent denied its obligation to pay, arguing that the medical certificates were insufficient and that the incapacity to work had not been adequately proven.

Procedural history: The appellant filed a claim with the Insurance Court of the Canton of Aargau on 11 September 2023, seeking payment of CHF 42,349.45 plus interest. The Insurance Court dismissed the claim by judgment of 14 June 2024. The appellant then filed an appeal in civil matters with the Federal Supreme Court, seeking the quashing of the cantonal judgment and either an order for the respondent to pay or a remittal to the lower court.

Considerations

1. Admissibility of the appeal The Federal Supreme Court reviews an appeal in civil matters against a final decision of an upper cantonal court that has decided as the sole instance. The appeal is admissible regardless of the value in dispute (Art. 74 para. 2 lit. b FSCA). The appeal concerns the interpretation of the General Insurance Conditions (GIC) and the lower court’s assessment of the evidence.

2. Interpretation of the GIC The GIC provide that incapacity to work must be due to illness and must be certified by a physician. The lower court interpreted the GIC as requiring, in addition to the medical certificate, proof of illness-related incapacity to work as a separate condition for entitlement to benefits. The appellant alleged a violation of Art. 55 CPC and claimed that the parties had agreed that the medical certificate alone would suffice. The Federal Supreme Court rejected this allegation, as the lower court had interpreted the GIC in accordance with the principle of trust and had not established a subjective consensus. The interpretation of the GIC as a matter of law is subject to review by the Federal Supreme Court, which is bound by the factual findings of the lower court.

3. Burden of proof and standard of proof The appellant bears the burden of proving the existence of illness-related incapacity to work (Art. 8 CC). The lower court incorrectly applied the standard of proof of the preponderance of probability, thereby lowering the requirements for the main proof. The Federal Supreme Court clarified that the ordinary standard of proof applies: proof is furnished if the court is convinced of the correctness of the factual allegation on objective grounds and no serious doubts remain (FSCA 148 III 105 para. 3.3.1).

4. Assessment of medical certificates The lower court…