INFORMATION SHEET ABOUT ACCIDENT INSURANCE UNDER THE FLAI applicable from 2016 on

Transcription

1 INFORMATION SHEET ABOUT ACCIDENT INSURANCE UNDER THE FLAI applicable from 2016 on Statutory basis for the insurance FLAI/GPSIL Individuals who are compulsorily insured The insurance is based on the FLAI of 20 March 1981 and the regulations relevant to the legislation. The information given below is an extract from the law, the regulations, and from the Federal Law on the General Part of Social Insurance Law of 6 October 2000 (GPSIL/ATSG). Insureds All employees, including those who work at home, paid and unpaid trainees and all apprentices, must be insured. Individuals working for an employer for the purpose of choosing a career are also insured compulsorily. Members of an employer s own family are also insured compulsorily if they draw wages in cash and/or pay contributions to the OASP fund. If a company only employs persons whose annual salary is CHF 2,300. or less per year, the company is not subject to the obligation to pay premiums. Cases of employees who suffer accidents while employed by such companies are handled by the FLAI/UVG Compensatory Fund. If an insured event occurs which is then processed by the Compensatory Fund, the employer is obliged to pay the Compensatory Fund compensatory FLAI premiums for the last five years at most. If a company employs at least one employee with an annual salary of more than CHF 2,300., the company is obliged to conclude a FLAI insurance contract for its employees. In this case all wages are deemed to be wages for which premiums are due, even if such are less than CHF 2,300. per year. Contributions have to be paid in every case for persons employed in private households, regardless of whether the wages earned are minimal. The foregoing also applies to employees working for creative artists. On agricultural premises the following are regarded as equivalent to independent farmers and are therefore not subject to the compulsory insurance requirement: the wife of the farm manager, relatives of the manager in ascending and descending order and their wives, further the sons-inlaw of the manager, who are expected to take over the farm in their own right as managers. Individuals who are non-compulsorily insured The following persons may be insured on the basis of a special agreement: The self-employed and members of their family who work in the same company and who are not compulsorily insured. Scope of insurance cover Insured accidents Part-time employment Beginning and end and dormancy of insurance cover Extension of accident protection Benefits are granted for occupational and non-occupational accidents. Occupational diseases are deemed to be the same as occupational accidents. Part-time employees, who are not employed by any employer for 8 hours or more per week, are only insured for occupational accidents. In the case of such employees accidents on the way to work are also deemed to be occupational accidents. Insurance cover begins on the day on which the employee begins work or should have begun work by virtue of being employed, in any case at the point in time when he sets out on the way to work. Cover ends on the lapse of the 30th day after that on which entitlement to at least half the salary ends. Wages are also deemed to be daily indemnity payments from the obligatory accident insurance, the Military Insurance (MV), the Disability Insurance (IV), and those from the health insurance and private sickness and accident insurers that are paid to replace continued salary payments, compensation paid under the legislation on compensation for loss of earnings and compensation from a cantonal maternity insurance. The insurance is dormant while the insured is in military service or is subject to a foreign compulsory accident insurance scheme. On the basis of a special agreement insurance for non-occupational accidents can be extended for a further maximum period of 180 days. The agreement must be made before insurance cover ends. V

2 Insurance benefits Treatment Abroad Home nursing Aids Damage to property Travel, transport and rescue costs Treatment and reimbursement of costs Costs are paid for a) outpatient treatment by a physician or dentist, or if prescribed by either, other medical personnel or a chiropractor; b) medicaments and analyses prescribed or requested by the physician or dentist; c) treatment, meals and accommodation in the general ward of a hospital; d) medically prescribed cures and spa cures; e) aids and objects serving the healing process. For necessary treatment abroad the insured will be reimbursed at most double the amount that would have arisen had treatment taken place in Switzerland. Contributions are paid for necessary home nursing inasmuch as the care is prescribed by a doctor and given by a person accredited to provide services under the health insurance legislation. The insured is entitled to specific aids that serve to compensate for physical injury or loss of use of functions (e.g. prostheses). Reimbursement is made for damage to property resulting from accidents for objects that replace a body part or bodily function (e.g. damage to existing prostheses). Claims for replacement of optical glasses, hearing aids and dental prostheses are only permitted if physical injury requiring treatment occurs. Costs are reimbursed for necessary rescue and recovery operations and for medically required travel and transport costs. Costs for rescue and recovery and travel and transport that arise abroad will be reimbursed up to a maximum of 20% of the highest insured annual income. Transport of mortal remains As a rule the costs incurred in transporting mortal remains to a burial place are reimbursed. Cost of burial and amount Deduction during stays in a sanatorium and amount Burial costs are reimbursed inasmuch as such do not exceed seven times the highest insured daily income. Daily indemnity If the insured become partly or entirely unfit for work because of an accident, he is entitled to a daily indemnity. The daily indemnity is paid for each calendar day and begins on the third day after the day of the accident. For the purpose of assessing the daily indemnity, the insured salary is deemed to be the last salary received before the accident occurred. to the indemnity ends when the insured person becomes fully fit for work, when pension payments begin, or on the death of the insured person. If the insured is completely unfit for work the daily indemnity amounts to 80% of the insured income, correspondingly less if the insured is partially fit for work. The daily indemnity is not granted while the insured person is entitled to a daily indemnity from the Disability Insurance (IV). During stays in a sanatorium the following amounts will be deducted from the daily indemnity for cost of living expenses covered by the accident insurance: a) 20% of the daily indemnity, however at most CHF 20.- for single persons with no duty to maintain or support dependents; b) 10% of the daily indemnity, however at most CHF 10.- for married persons and for single persons with a duty to maintain and support dependents, provided paragraph c) does not apply; c) no deduction is made in the case of married or single persons caring for minors or children who are still in education. Disablement pension If the insured is rated as being at least 10% disabled as a result of an accident, he is entitled to a disablement pension. If the insured is completely disabled, a pension amounting to 80% of the insured income is paid and correspondingly less if the insured is partially fit for work. For the purpose of assessing the pension, the insured income is deemed to be the wages received within the year prior to the accident. If the insured is entitled to a pension from either the Disability Insurance (IV) or from the Old-Age

3 and Survivors Pension fund (OASP) he will be granted a complementary pension which supplements the IV or OASP pension until the amount received is equal to 90% of the insured income; the highest amount paid out will be that for partial or full disability. Revision Pension If the degree of disability of a pension recipient changes substantially the pension will in future be either increased, decreased or cancelled correspondingly. Integrity indemnity If the insured suffers substantial, permanent injury impairing his physical or mental integrity through the accident he is entitled to an appropriate loss of integrity indemnity in the form of a capital payment. Indemnity for full invalids If the insured becomes a full invalid requiring permanent daily assistance from a third party or permanent supervision he is entitled to an invalidity indemnity. Survivor s pension If the insured dies as a consequence of an accident the surviving spouse and children are entitled to a survivor s pension as provided for in the legislation. The survivor s pensions are shown below as a percentage of the insured income: - widowers and widows 40% - orphans who lose one parent 15% - orphans who lose both parents 25% - for a number of survivors at most in total 70% If survivors are entitled to a pension from either the OASP fund or the Disability Insurance (IV), as a group they will be granted a complementary pension which supplements the OASP and/or the IV pension until the amount received is equal to 90% of the insured income; the highest amount paid out will be that resulting from the scale shown above. Insured income Daily indemnities and pensions will be assessed on the basis of the insured income. As a rule the insured income is deemed to be the wages subject to contributions to the OASP fund up to a maximum of CHF per year, or CHF per day. Wages on which no contributions are paid to the OASP fund because of the age of the insured also count as insured income as do family allowances granted as supplements for children, education or assistance in the household. Cost-of-living increases for pensions As a rule pensions are modified every two years to take account of rises in the cost of living according to the information in the index of consumer prices. Coincidence of different causes Culpably causing an accident Reduction and refusal of insurance benefits Disability pensions, integrity indemnities and survivor s pensions will be reduced appropriately if the damage to health or death is only partly due to the consequences of an accident. If an insured person causes an accident through gross negligence, the indemnity for nonoccupational accidents which is paid during the initial two years after the accident will be reduced. In addition, payments (daily indemnity, pensions, integrity indemnity and attendance allowance) may be reduced if the insured person has caused the accident through non-willful participation in the execution of a crime or offence; in particularly serious cases payments may be refused. If a survivor willfully causes the death of the insured through gross negligence, the cash benefits due will be reduced; in particularly serious cases benefits may be refused. Exceptional dangers All insurance benefits will be refused for accidents that occur during service in a foreign army and while participating in acts of war, acts of terror and organized criminal acts. Cash benefits will be reduced by half for non-occupational accidents that occur under the following circumstances: a) participation in brawls and fights unless, while otherwise uninvolved, the insured is injured by the protagonists or while coming to the assistance of a defenseless person b) dangers to which the insured exposes himself by seriously provoking others c) participation in disturbances.

4 Hazardous activities In the case of non-occupational accidents caused by engaging in hazardous activities, cash benefits will be halved and in particularly serious cases payment will be refused. Hazardous activities are activities through which the insured is exposed to exceptional danger through not taking, or while unable to take, measures to reduce the risk to a reasonable level. A difference is made between activities which are absolutely hazardous and those which are relatively hazardous. Activities which are absolutely hazardous involve an insured person voluntarily exposing himself to an especially large risk of accident that cannot be reduced to a reasonable level regardless of the specific circumstances. The following activities are deemed to be absolutely hazardous activities: base-jumping, deliberately breaking glass, racing on racing circuits and motocross racing, etc. Activities which are relatively hazardous are those which involve the insured person voluntarily exposing himself to an especially large risk of accident that can be reduced to a reasonable level by taking the necessary precautions. Activities such as mountaineering or climbing without the proper equipment and experience or paragliding when wind conditions are unsuitable are deemed to be relatively hazardous. Rescue operations on behalf of other people are nevertheless insured although such are considered to be hazardous activities. Procedure when an accident occurs Notification of an accident Consequences of neglecting to inform the insurer Claim processing / Use of personal data Medical examination The injured party or his relatives must notify the insured s employer or the insurer without delay. The employer must notify the insurer without delay as soon as he learns that an insured person has had an accident. If the insured or his survivors inexcusably neglect to inform the insurer about the accident thus leading to substantially more work for the insurer, the payments due in the interim may be reduced by half. In addition, the insurer may halve each benefit paid if the insured or his survivors do not notify the insurer about the accident or the death within a period of three months; the insurer may refuse to pay benefits entirely if fraudulent notification of an accident is received. If the employer inexcusably neglects to inform the insurer of the accident, the insurer can hold him liable for subsequent costs. Visana can obtain information from third parties (employers, doctors, hospitals, social insurers, etc.). Visana uses data in particular to determine premiums, for risk assessment, to process insurance claims, and for statistical purposes. Data is stored physically and/or electronically. The insured person has to agree to the measures requested by the insurer to clarify the case, in particular the insured person has to submit to reasonable medical examinations that serve to diagnose the case and establish the benefits to be paid. The insurer bears the costs of such examinations. Premiums Duty to pay premiums Due date for payment Delay for payment Settlement of premiums The premiums for compulsory insurance to cover occupational accidents and occupational diseases are borne by the employer. Premiums for compulsory insurance to cover nonoccupational accidents are paid by the employee. Other arrangements in favor of the employee are permitted. The employer owes the entire premium sum. The employer deducts the employee s share from his wages. The premium is determined for each insurance year and is due in advance on the date indicated in the policy. The delay for payment of premiums is one month after the due date. If the deadline for payment is not observed on expiry of this period interest on arrears of 0.5% per month will be charged to the account of the employer. At the beginning of the insurance year the provisional premium determined in the policy is to be paid. The final settlement of the premium takes place at the end of the insurance year on the basis of information to be provided by the policyholder. If the resulting balance is less than CHF 20.- no invoice will be sent, i.e. the provisional premium is deemed to be the final premium. The premium settlement is based on the wages for which contributions are paid to the OASP fund provided this does not exceed the highest insured income permitted. Further details can be found on the wage declaration form. If an all-inclusive premium is contracted for no settlement is required. Nevertheless, in such cases the policyholder still has a duty to keep salary lists.

5 The insured has the right to check information provided by the policyholder by examining all relevant paperwork (salary lists, OASP fund settlements, etc.). Accident prevention Legal regulations Duties of the employer and employee Regulations are provided for in the legislation to prevent accidents and occupational diseases. With the cooperation of employees the employer has to adopt prevention measures suitable to the circumstances. Employees in particular have a duty to use their personal protective clothing and make use of the available safety apparatus. Insurance carrier Visana Insurance Ltd, Weltpoststrasse 19, 3000 Bern 15 Please note To make this document easier to read only the male pronoun is used.