The case in brief

A tree surgeon, the victim of a serious occupational accident that caused him to lose half the functionality of his left hand, was denied payment of the disability pension provided for in his insurance contract by Generali Vie. The insurer considered that the insured’s overall disability rate did not reach the contractual threshold of 33%. The Court of Cassation, seized after an unsuccessful appeal, quashed the judgment of the Toulouse Court of Appeal and called into question the calculation method used by the insurer — in the name of a fundamental principle of consumer law: ambiguous clauses must be interpreted in favour of the consumer.

The facts: a serious accident, compensation denied

In February 2002, Mr [C] joined the “Atout Prevoyance” group contract taken out by an association with Eagle Star Vie, whose rights were subsequently assumed by Generali Vie. This contract guaranteed him, among other things, the payment of daily allowances and a disability pension in the event of incapacity.

On 29 July 2015, while working as a salaried tree surgeon, Mr [C] was the victim of an occupational accident: while handling a chainsaw, he suffered a deep wound to the left wrist, with median nerve damage. The consequences were severe — stiffening of the fingers, sensory disorders, and loss of half the hand’s functionality.

The MSA (Mutualite sociale agricole) medical adviser consolidated his condition as of 30 September 2018 and recognised a permanent partial disability (PPD) rate of 45%, subsequently increased to 47% following a relapse.

Generali Vie paid him daily allowances for the maximum period of 1,095 days. However, when it came to transitioning to the disability pension, the insurer refused. Its medical adviser, applying the Concours medical scale (the so-called “general law” scale), retained a functional disability rate of only 12%. Combined with the occupational disability rate of 100%, the overall disability rate obtained through the contractual cross-reference table remained below the 33% threshold — and the pension was denied.

The contractual mechanism at stake

To properly understand the dispute, one must grasp the mechanics of the “Atout Prevoyance” contract. Article 9.4 of the information notice provides that the overall disability rate (T) results from the combination of two distinct components:

the occupational disability rate, assessed by the insurer’s medical adviser with regard to the profession exercised;
the functional disability rate, assessed by the same medical adviser “on the basis of the information provided to him.”

These two rates are cross-referenced in a double-entry table. If the resulting overall rate is below 33%, no pension is payable. If it falls between 33% and 66%, the pension is proportional. Above 66%, it is paid in full.

The crux of the problem lies in the contract’s silence on a crucial point: which scale should be applied to assess functional disability? The contract does not specify. It merely states that this disability “is assessed by the medical adviser on the basis of the information provided to him.”

The judicial journey: two rejections before cassation

At first instance (TJ Castres, 12 May 2022)

The Castres Judicial Court dismissed Mr [C]’s claim. It considered that the MSA’s PPD rate (45%) could not be equated with functional disability within the meaning of the contract, and that the discrepancy between 45% and 12% was not sufficient to call into question the insurer’s assessment.

On appeal (CA Toulouse, 28 February 2024)

The Toulouse Court of Appeal upheld the judgment. Its reasoning rested on three pillars:

The PPD rate retained by the MSA encompasses both the functional and occupational dimensions — it therefore cannot be transposed as is for the sole functional disability component of the contract, without distorting its terms.
While the contract admittedly does not mention any scale, Mr [C] fails to prove that under a compatible scale, his functional rate would be sufficient to qualify for the pension.
Mr [C] produces no medical evidence contradicting the insurer’s medical adviser’s opinion.

The subsidiary request for a court-ordered medical examination was also rejected on the basis of Article 146 of the Code of Civil Procedure: an expert examination cannot compensate for a party’s failure to discharge its burden of proof.

Before the Court of Cassation (Cass. 2e civ., 18 December 2025)

Mr [C] filed an appeal in cassation based on a single ground, the second branch of which invoked Article L. 133-2 (now L. 211-1) of the Consumer Code.

The Court of Cassation’s decision: recalling a fundamental requirement

The reasoning of the Second Civil Chamber is remarkably clear and follows a rigorous syllogism.

The principle (para. 8): clauses in contracts offered by professionals to consumers must be presented and drafted in a clear and comprehensible manner. In case of doubt, they must be interpreted in the sense most favourable to the consumer.

The finding (para. 12): in the absence of a definition of functional disability and of any reference to an evaluation scale, the disputed clause does not contain sufficient information to enable an average consumer, normally informed and reasonably attentive and circumspect, to understand the calculation of the disability rate determining the granting of the pension. The clause is therefore not clear and comprehensible.

The sanction: the Court of Appeal, which interpreted this clause in a sense favourable to the insurer (by validating the application of the Concours medical scale unilaterally chosen by the latter), violated Article L. 133-2 of the Consumer Code.

The judgment was quashed and the case referred back to the Toulouse Court of Appeal, differently composed. Generali Vie was ordered to pay costs and to pay Mr [C] 3,000 euros pursuant to Article 700 of the Code of Civil Procedure.

Practical lessons from this decision

1. The requirement of contractual transparency applies concretely to evaluation scales

This ruling illustrates a common scenario in disability insurance: the contract provides a mechanism for calculating the disability rate but remains silent on which scale to use. This silence is not neutral. It creates an opacity that structurally benefits the insurer, who can then choose the most restrictive scale — here, the Concours medical scale, which yields a functional rate of 12%, whereas the occupational accidents scale yielded 45%.

The Court of Cassation sanctioned this situation: if the insured does not have the information necessary to understand how the rate conditioning the payment of their pension will be calculated, the clause is not clear and comprehensible. The interpretation must then operate in their favour.

2. The “average consumer” standard as an assessment criterion

By expressly adopting the notion of an “average consumer, normally informed and reasonably attentive and circumspect,” the Court anchors its reasoning in European consumer protection law. The reference point is not the specialist lawyer, but the ordinary policyholder — the tree surgeon who signs a disability insurance contract legitimately believing he will be covered in the event of a serious accident.

3. The impossibility of placing the burden of proof on the insured when a clause is ambiguous

The Court of Appeal reproached Mr [C] for failing to demonstrate that, “under a scale of his choosing compatible with the contract,” his rate would qualify him for the benefit. This reasoning is implicitly censured by the Court of Cassation: when a clause is ambiguous, it is for the insurer to bear the consequences, not for the insured to guess which scale would be acceptable.

4. Broad implications for group insurance contracts

Many disability insurance contracts of the “Atout Prevoyance” type are drafted using similar formulas — a double-entry table, a distinction between functional and occupational disability, and silence on the applicable scale. This decision serves as a clear warning to insurers: in the absence of an explicit mention of the scale in the contractual documents, the interpretation most favourable to the consumer will prevail.

Conclusion

This ruling of 18 December 2025 forcefully recalls that consumer protection is not merely an abstract principle. Faced with an insurer that exploits contractual ambiguity to apply the most unfavourable scale to its policyholder — transforming a disability rate of 45% into 12% through the mere choice of a reference framework — the Court of Cassation restores the balance. Contractual clarity is not optional for the insurance professional; it is an obligation, the breach of which operates in favour of the insured.

The case, referred back to the Toulouse Court of Appeal in a different composition, must now be reheard in light of this principle: in case of doubt, the interpretation most favourable to the insured prevails.

References: Cass. 2e civ., 18 December 2025, No. 24-16.217, F-D — Article L. 211-1 (formerly L. 133-2) of the Consumer Code — CA Toulouse, 3rd Ch., 28 February 2024, No. 22/02188.

FAQ – Challenging the Disability Scale Applied by Your Insurer

My insurer applied a very low functional disability rate: is this normal?

Not necessarily. Insurers appoint their own medical advisers, who often apply the Concours medical scale (the general law scale), which frequently yields rates far lower than those retained by Social Security or the MSA for the same injuries. If your insurance contract does not specify which scale must be used, this unilateral choice can be challenged. The Court of Cassation held on 18 December 2025 that a clause mentioning neither the definition of functional disability nor the applicable scale is not clear and comprehensible, and must therefore be interpreted in favour of the insured (Cass. 2e civ., 18 Dec. 2025, No. 24-16.217).

What is the difference between the Concours medical scale and the occupational accidents scale?

The Concours medical scale assesses impairment to physical integrity independently of any occupational context. It generally produces lower rates. The indicative scale for occupational accidents and diseases (Order of 10 January 1995) takes greater account of the overall impact of the sequelae. For the same hand injury, the difference can be considerable: in the case decided by the Court of Cassation in December 2025, the insurer’s physician retained 12% while the MSA retained 45%. The choice of scale is therefore decisive in determining whether you reach the contractual threshold entitling you to the pension.

My contract does not specify the applicable scale: what does the law say?

Article L. 211-1 of the Consumer Code (formerly L. 133-2) requires that clauses in contracts offered by professionals be drafted in a clear and comprehensible manner. If the contract does not mention the scale for evaluating functional disability, the clause is considered ambiguous. In case of doubt, it must be interpreted in the sense most favourable to the insured — not in the sense chosen by the insurer.

My insurer refuses my disability pension: what are my remedies?

You may challenge your insurer’s refusal through amicable means (formal letter of dispute sent by registered mail, referral to the insurance ombudsman), and then through legal proceedings before the competent court. A lawyer specialising in insurance law can analyse your contract, verify whether the scale applied complies with the contractual provisions, and if necessary request a court-ordered medical examination or the application of the scale most favourable to your situation.

Can I request a court-ordered medical examination?

Yes, but such a request must be supported by evidence. Courts refuse to order an expert examination to compensate for a party’s failure to meet its burden of proof (Article 146 of the Code of Civil Procedure). It is therefore essential to produce medical evidence — certificates, reports, specialist opinions — that substantiate a serious challenge to the rate retained by the insurer’s physician. A lawyer can assist you in compiling this medical file.

Does this case law apply to my insurance contract?

The ruling of 18 December 2025 concerns a group contract of the “Atout Prevoyance” type with a standard double-entry table mechanism (functional disability x occupational disability). A very large number of individual or group insurance contracts use similar mechanisms without specifying the applicable scale. If this is the case with your contract, this case law may constitute a decisive argument in your dispute with your insurer.