Fact sheet: accident insurance
Patient information on reporting an accident – to print (in German)
It often happens that someone is injured and believes it was an accident, and the case is reported to the accident insurer. This fact sheet explains under what conditions the insurer actually pays and what it pays for, who is insured at all, and much more.
What is insured?
Accident insurance covers not only accidents, but also accident-like bodily injuries and occupational diseases.
a) What is an accident?
Not everything that is called an accident in everyday language counts as an accident in law. For lawyers, the exact course of the event that led to the injury determines whether there really was an accident. For an accident, the following conditions must be met:
- An external factor acts on the human body (i.e. not from inside the body)
- The effect is sudden (i.e. not continuous or gradual, as with sunburn, for example)
- The factor acts on the human body unintentionally
- The external factor is unusual, i.e. goes beyond the everyday and the ordinary
- The effect leads to physical, emotional or psychological injury, or to death
b) What are accident-like bodily injuries?
These exist when all the conditions are met except that the external factor is not unusual. In that case the accident insurer pays. For an injury to count as an accident-like bodily injury, it must be one of the injuries listed below (exhaustive list), and it must on no account be due to illness or wear and tear. There must be an increased level of danger or a certain lack of control over the situation.
- Fractures
- Dislocated joints
- Torn menisci
- Torn muscles
- Pulled muscles
- Torn tendons
- Ligament injuries
- Eardrum injuries
c) What is an occupational disease?
An occupational disease is an illness caused by one's work.
The following count as occupational diseases:
- Illnesses at least 50% attributable to work with certain harmful substances or other influences (e.g. vibration or noise); the Federal Council has drawn up a list of these harmful substances (listed substances) and of the typical illnesses caused by other influences (listed diseases). These lists can be found in Annex 1 to the Accident Insurance Ordinance (in German).
- Other illnesses that have demonstrably been caused at least 75% by one's work. However, this is not very easy to prove.
Who is insured?
In principle, all employees in Switzerland must be insured against accidents with an accident insurer. There is no minimum or maximum age, so apprentices and pensioners are also compulsorily insured if they are employed.
Employees who work 8 hours or more a week for one employer are insured against both leisure-time accidents (so-called non-occupational accidents) and occupational accidents. Other employees are only insured against occupational accidents and must insure non-occupational accidents with their health insurer (basic insurance).
What benefits does accident insurance provide?
Medical treatment (without deductible or co-payment)
- Medical home care
- Aids and appliances
- Contribution to travel and transport costs and other costs
- Daily allowance (80% of the last salary before the accident, 80% of a maximum of CHF 10,500)
- Compensation for loss of integrity (e.g. loss of a part of the body)
- Helplessness allowance
- Survivors' pensions / lump sums (orphan's, widow's and widower's pensions, pension for divorced spouses)
- Disability pension (from a degree of disability of 10%)
What to do if the accident insurer refuses to pay?
The accident insurer may accept that there was an accident but still refuse to pay, usually because it believes there is no causal link between the accident and the injuries. There is a causal link if the event is the direct cause of the injury.
If the accident insurer does not pay, compulsory health insurance (basic insurance) is responsible. The disadvantage for the insured person is that they have to pay the deductible and co-payment, and basic health insurance does not provide, for example, a daily allowance or pension.
If the accident insurer rejects a case, it must notify the insured person in a formal written decision. An objection can be lodged within 30 days of receipt (the postmark is not decisive). If the insurer sends the rejection in an ordinary letter, you can request a formal decision at any time so that you can object. The procedure is free of charge; costs only arise if you appeal to the Federal Supreme Court.
Articles (in German)
Source: www.beobachter.ch