Self-employed Persons Voluntary Accident Insurance

Transcription

1 PRODUCT DESCRIPTION Valid as of 1 January 2013 Self-employed Persons Voluntary Accident Insurance Low-cost cover for self-employed persons in case of accidents Given that self-employed persons and entrepreneurs are not covered by statutory workers compensation insurance, they are dependent on public health insurance in case they sustain an accidental injury. However, self-employed persons can substantially supplement their insurance cover by taking out our selfemployed persons voluntary accident insurance which is valid not only during working hours but also during leisure time.

2 Cover for accidental injuries and occupational diseases Self-employed persons accident insurance covers costs and loss of income resulting from accidents and occupational diseases sustained by self-employed persons. It is a voluntary policy as per the Finnish Employment Accidents Insurance Act and is valid both during working hours and leisure time throughout the world. The extensive cover provided by the insurance can be granted to private entrepreneurs and owners who work for their company and who are not covered by the statutory workers compensation insurance. Benefits Unlike in self-employed persons accident insurance, compensation paid by the Social Insurance Institution of Finland (Kela) on the basis of the Health Insurance Act includes restrictions and qualifying periods. In addition to daily allowance paid under self-employed persons accident insurance, a person injured in an accident may also be entitled to daily allowance as per the Health Insurance Act. Self-employed persons voluntary accident insurance provides wide and extensive compensation in case of accidents. For instance, the injured person is entitled to daily allowance for each day after the accident day, provided that his incapacity for work has lasted at least three days running after the accident day. No maximum compensation applies to medical treatment expenses. The insurance also covers sports accidents provided that no earned or other income is paid for sports. Insurance premiums are tax-deductible in the company s taxation and can be flexibly paid in instalments. Scope of cover of self-employed persons accident insurance The insurance covers accidental injuries sustained at work or in leisure time and occupational diseases in accordance with the Employment Accidents Insurance Act in force. The terms and conditions of the self-employed persons accident insurance include some exclusions related to compensation. For example, the insurance does not provide cover against road accidents or assaults during leisure time. Who are eligible for self-employed persons accident insurance? The table below shows who is covered by statutory workers compensation insurance and who is eligible for self-employed persons accident insurance. Type of business organisation Those covered by statutory insurance Those eligible for voluntary accident insurance Limited liability company Limited partnership General partnership Proprietorship or private entrepreneur Shareholder not in executive position. Shareholder who holds a maximum of 50% of the company s shares alone or together with his family. General partner who, alone or together with his family, has a maximum of 50% of the general partners control / of the total partnership shares. Limited partner. Hired family member of partner. Partner who, alone or together with his family, has a maximum of 50% of partnership control / partnership shares. Hired family member of partner. Hired common-law spouse. Hired common-law spouse of employer s family member Shareholder in executive position holding over 50% of the company s shares alone or together with his family. General partner who, alone or together with his family, has over 50% of the general partners control/of the total partnership shares. Partner who, alone or together with his family, has over 50% of partnership control/ partnership shares. Employer himself or his common-law spouse or family member. Points to note for limited liability companies For the family members shares to be taken into account and added to the personal holding, the person himself must hold at least one share. When spouses hold the share capital on a 50/50 basis, they are both excluded from the obligation to insure if they both hold an executive position simultaneously. When common-law spouses have a 50/50 holding of the share capital, they are both covered by insurance on an obligatory basis if they work for the company. Executive position refers to a managing director, chairman of the board of directors or a regular board member. Other senior management duties are also regarded as executive positions when they involve equivalent decision-making powers exercised daily. The number of votes conferred by shares is not taken into account in the determination of whether or not shareholders are covered by statutory workers compensation insurance. A holding through another company is not taken into account in a limited liability company or in any other type of business organisation. Points to note for limited partnerships When spouses own the general partners partnership share on a 50/50 basis, neither of them is covered by the obligation to insure. Common-law spouses in a corresponding situation are both covered by the insurance on an obligatory basis when working for the company. Who is considered a family member? Under the Employment Accidents Insurance Act, a family member is a person living permanently in the same household as a 2

3 private entrepreneur, shareholder or partner, and who is related to him/her or to his/her spouse in direct ascending or descending line, or is his/her adopted child or adoptive parent or a spouse of any person mentioned above. In addition to a spouse, family members include grandparents, and children and their spouses, provided that they live permanently in the same household as the employer. Living in the same household means that the family member does not pay any compensation to the employer for accommodation and expenses. Those living in a registered partnership (civil union) are regarded as spouses. In determining whether a person is covered by workers compensation insurance, a common-law spouse is not a family member of a private entrepreneur, partner or shareholder. The common-law spouse of a private entrepreneur is covered as an employee to be insured on an obligatory basis when he works for the company and receives remuneration. The common-law spouse of a shareholder or partner working for a company is covered by insurance on an obligatory basis unless the common-law spouse holds shares or partnership shares. A common-law spouse may be excluded from the obligation to insure on the grounds of personal ownership and status. Professional athletes Professional athletes cannot take out self-employed persons accident insurance but they must be insured under obligatory sports insurance for professional athletes. This has been enacted in the Finnish Act on athletes accident and pension cover (575/2000). Premium determined on the basis of risk involved at work and of the agreed annual earnings The insurance premium is determined by the type of work and the agreed annual earnings. The type of work is defined based on information provided by the self-employed person on his duties. The agreed annual earnings must correspond to the average salary paid for the work or to a salary which would be paid for the same work to an equally qualified person. Thus, the parties must primarily determine the annual earnings to equal the amount of earned income confirmed in pension insurance for self-employed persons (YEL insurance) under the Self-employed Persons Pensions Act, and such earnings are annually adjusted by the TyEL index (TyEL = the Finnish Employees Pensions Act). The agreed annual earnings amount to at least the minimum annual earnings annually confirmed by the Ministry of Social Affairs and Health. Flexible premium instalments according to the agreed schedule The insurer charges the self-employed persons accident insurance premium in advance for each insurance period. The premium may also be paid in several instalments, subject to a surcharge. Responsibility for notifying changes According to the insurance terms and conditions, the company or private entrepreneur which has taken out self-employed persons accident insurance is obliged to notify the insurer of any changes in information on those insured. Such changes in information include factors affecting the premium: change in the type of work, or in occupation or position at the company. 3 Information relevant to the validity of the policy include changes in the insured person s personal data, changes in the type of business organisation and ownership, and interruption or termination of business. Self-employed persons accident insurance as implied by the name is designed for private entrepreneurs or owners working for their companies. Self-employed persons accident insurance covers costs, loss of income and handicap Medical treatment and examination expenses Self-employed persons accident insurance covers in full any expenses incurred due to treatment of occupational diseases and accidental injuries given in a private medical centre or private hospital in Finland. Such expenses include doctors fees, medication, medical examination and treatment expenses and daily hospital charges. The insurance covers such expenses provided that the examination or treatment is prescribed by a physician and necessary for examination and treatment of the injury. Pohjola has an extensive nationwide network of partner hospitals and clinics which enables us to ensure quick access to treatment and effective rehabilitation. A commitment to pay issued by Pohjola for treatment at our partner hospital/clinic enables the insured person to ensure in advance that, for example, costs of an MRI scan or an operation is paid under his self-employed persons accident insurance. Omasairaala hospital established by Pohjola has been part of our partner network since early The hospital specialises in treatment of musculoskeletal injuries, which account for the majority of accidental injuries, and boasts top diagnostics technologies and medical care. Services ranging from referral to treatment, a claim settlement decision, imaging and surgery to rehabilitation are all readily available at Omasairaala after check-in. This enables quick access to treatment and rehabilitation, good medical treatment results and the best customer experience. If an injury is suspected to be an occupational injury or a disease an occupational disease, any necessary expenses arising from finding out the reason for the injury or disease are covered under the insurance, even if the findings of the examination show that the disease was not an occupational disease or that the injury was not caused by an occupational accident. Any justifiable and necessary medical examinations and related travel expenses are covered as examination expenses. The insurance does not cover any loss of income arising from examinations. Daily allowance Daily allowance will be paid if the insured person is fully or partly unable to work for at least three consecutive days following the day on which the accident occurred. Daily allowance is paid for all calendar days for a maximum of one year excluding the day of the accident. Daily allowance accounts for one 360th of the agreed annual earnings. Industrial injuries pension Compensation for loss of income becomes industrial injuries pension in one year s time after the accident. An injured person is eligible for industrial injuries pension if his working capacity has reduced by at least 10 per cent. An injured person s ability to earn income from work that can reasonably be required of him will be taken into account in assessing his working capacity. The injured person s age, education, work experience and place of residence include aspects to be taken into account in such assessment.

4 Full industrial injuries pension accounts for 85% of annual earnings until the pensioner reaches the age of 65. After that, full pension accounts for 70% of annual earnings. Industrial injuries pension is subject to an annual index increment. Handicap benefit The insured person will be eligible for handicap benefit if an occupational injury or occupational disease causes permanent handicap affecting his ability to function. Such assessment will take account of general activity limitations caused by the injury or disease but not individual circumstances such as occupation or hobbies. The amount of handicap benefit is based on the handicap classification confirmed by the Finnish Ministry of Social Affairs and Health. Handicap classes number 20. If the handicap class is between 1 and 10, the handicap benefit will be a lump-sum benefit. For handicap classes 11 20, the benefit payable will be a lump-sum benefit or a continuous benefit, depending on the injured person s choice. The insured person will be eligible for handicap benefit provided that the status of his injury or disease has become stable, but no earlier than one year after the accident or the diagnosis of the occupational disease. Rehabilitation Self-employed persons accident insurance covers costs related to occupational rehabilitation and functional capacity rehabilitation. Occupational rehabilitation is aimed at the injured person being able to return to the work he did at the time of the accident or to a completely new work. Functional capacity rehabilitation involves tools that promote the injured person s general functional abilities and enable him to cope with daily activities. As part of the costs of occupational rehabilitation, the insurance covers costs, for example, of work try-outs, retraining and financial support to the company. The injured person is eligible for full industrial injuries pension for the rehabilitation period and the rehabilitation investigation and waiting period. In addition, the insurance covers costs of studying. The injured person may be entitled to partial industrial injuries pension if his earnings in his new job are lower than earlier. As part of the costs of functional capacity rehabilitation, the insurance covers, for example, physiotherapy, periods of hospitalbased rehabilitation, aids and alterations in the home. Effective and timely rehabilitation can shorten the period of disability caused by accidental injury or occupational disease and contribute to the injured person regaining his working and functional capacity. Pohjola will discover the need for rehabilitation at the earliest possible stage and refer the injured person to the services required. Pohjola has a nationwide network of partners, which enables a quick and effective rehabilitation process. Survivors pension A widow(er) and the deceased person s children under 18 years of age are entitled to survivors pension. However, full-time students or children unable to work are entitled to survivors pension until they reach the age of 25. A child of the beneficiary of surviving spouse s pension is also eligible for survivors pension if the deceased person arranged the child s maintenance The spouse or the registered partner of the deceased person is entitled to surviving spouse s pension. The common-law-spouse is entitled to surviving spouse s pension if the spouses have a child together or a mutual child maintenance agreement. The amount of the survivors pension depends on the number of those entitled to the pension. Surviving spouse s pension accounts for a maximum of 40% of the deceased person s annual earnings. Pension payable to one child is a maximum of 25%. Survivors pension accounts for a maximum of 70% of the deceased person s annual earnings. The widow(er) s personal income will reduce the pension benefit if it exceeds the amount specifically confirmed in the Employment Accidents Insurance Act. However, the beneficiary is always entitled to full surviving spouse s pension for the 12 month period following the insured person s death. Other compensation Some other forms of compensation are also paid out under the self-employed persons accident insurance, such as supplementary handicap benefit, extra household management costs and funeral grant. Compensation vs. other statutory forms of compensation A notable benefit is that the injured person may also be entitled to daily allowance as per the Finnish Health Insurance Act, in addition to the daily allowance paid under the self-employed persons accident insurance with the exception of road accidents. Self-employed persons accident insurance covers road accidents if they occur at work or on the way to/from work. Another insurance providing cover for such accidents is motor liability insurance. Because motor liability insurance is a statutory policy, the Social Insurance Institution of Finland (KELA) does not pay compensation on the basis of the general Health Insurance Act. On the other hand, motor liability insurance does not indemnify the injured party for the portion of the daily allowance or of expense compensation which has been covered under self-employed persons accident insurance, because in motor liability insurance, self-employed persons accident insurance is considered to be comparable to other forms of statutory insurance as it is based on the Employment Accidents Insurance Act. In these cases, however, the policyholder can file a claim, for instance, for pain and suffering under motor liability insurance. Injuries sustained in road accidents in leisure time are not covered under self-employed persons accident insurance. Employee pension insurance companies integrate any compensation for loss of income paid under self-employed persons accident insurance, provided that the injured person is, on the basis of the same injury, also entitled to disability pension under statutory employee pension insurance. Filing a complaint or an appeal in case you are dissatisfied with our claim settlement decision A person dissatisfied with a claim settlement decision should first contact Pohjola. Pohjola may rectify the decision, whenever deemed necessary. Each claim settlement decision that we send to claimants is accompanied by the instructions on how to file a complaint or an appeal. If Pohjola cannot rectify itself the decision on the basis of the complaint made and of the supplementary information provided, it will submit the complaint to the Employment Accidents Appeal Board. If the decision made by the Employment Accidents Appeal Board is not in your favour, you may appeal to the Insurance Court and if its decision is not in your favour, you may file a petition for leave of appeal with the Supreme Court. The appeal process is free of charge across the board. 4

5 Benefits and compensation paid under the Employment Accidents Insurance Act Type of compensation/benefit Daily allowance Amount of compensation/benefit Period of compensation Special information Amount equalling the selfemployed person s agreed annual earnings. Duration of incapacity for work for a maximum of one year. It is possible to receive daily allowance granted by KELA under the Health Insurance Act for the same period. Industrial injuries pension Full pension 85% of annual earnings; 70% from the age of 65. No earlier than in 12 months time following accidental injury; no time limit. Entitlement for a fixed term or until further notice. Occupational rehabilitation Daily allowance or industrial injuries pension and the costs of rehabilitation for the rehabilitation period. Retraining typically for a suitable occupation. Medical care costs Full compensation for necessary medical care. Also cover medication, medicinal products and travelling expenses related to medical care. Costs of treatment given at a private clinic or private hospital are coverable. Pohjola has an extensive network of partner hospitals/clinics. Functional capacity rehabilitation Full compensation. Aided living: fixed compensation based on law. Aids, home alterations, rehabilitation periods, rehabilitation examinations, aided living, adaptation training and other comparable costs. Handicap benefit Benefit based on the handicap classification and paid due to permanent general handicap caused by injury or disease. Payment no earlier than in one year s time. Lump-sum compensation or a continuous benefit paid throughout the life time, depending on the beneficiary s choice. Personal earnings, work or hobbies have no effect on the amount of the benefit. Supplementary handicap benefit Daily allowance for exceptional handicap or incapability caused by injury. Not paid during the period of hospital care or institutional care. Clothing allowance Daily allowance for wear and tear of clothing caused by artificial limb or medicinal aid. Requires long-term use of an artificial limb or medicinal aid. Guide dog allowance Daily allowance for the cost of maintaining a guide dog. Household management costs Reasonable and necessary extra costs. For a maximum of one year. Cleaning, grocery shopping, snow removal or similar. Survivors pension Maximum benefit 70% of the agreed annual earnings Widow(er) s personal earnings at the time of the insured person s death may reduce the pension benefit no earlier than one year after the death. No time limit applies to the widow(er) but his entitlement will terminate in the case of remarriage. Until the child reaches the age of 18. Until the child as student or disabled reaches the age of 25. Widow(er) refers to the deceased person s spouse, registered partner or a common-law spouse if they have a child together or a mutual child maintenance agreement. Only one person may be entitled to surviving spouse s pension. Funeral grant Grant paid to the decedent s estate and determined by the year of death. Lump-sum benefit. Agreed annual earnings have no effect on the amount. Material damage Full compensation payable for spectacles, hearing aids, dental prosthetic, artificial limbs or similar damaged during the accident. Lump-sum benefit. Clothes and rings cut off during emergency procedures are also coverable. Other material damage are not coverable. Examination costs Full compensation for necessary medical examination although the injury or disease does not prove to have been caused by an occupational accident or disease. Necessary and justified medical examinations on a case-by-case basis. 5

6 /2013 Examples of compensation for loss of income Example 1 A self-employed hairdresser took out self-employed persons accident insurance with Pohjola. Her annual earnings were set at 18,500 euros. The insurance was valid both at work and during leisure time. The hairdresser developed a serious rash following the use of hairdressing chemicals. Owing to the occupational disease, she had to stop working at the age of 37. After a year-long daily allowance period, she received, under the insurance, a taxable annual pension of 15,725 euros increased by the TyEL index. In addition, the hairdresser received compensation for a three-year training course for a new occupation. After the training, she immediately got a job. Her earnings remained unchanged when the new earnings were compared to the agreed annual earnings increased by the TyEL index. She was entitled to industrial injuries pension during the entire training period. Other trainingrelated expenses were also covered in accordance with the confirmed norms. Example 2 Self-employed persons accident insurance was taken out for the Managing Director of a company. He holds 75% of the company s shares. His annual earnings were set at 42,000 euros. The Managing Director fell over when snowboarding during his leisure time, with the result that his right wrist was fractured and he was taken to a medical centre. Following the accident, he was on sick leave for 90 days. In addition to medical treatment expenses, the insurance paid out daily allowance of euros per day for 90 days, which totalled 10,500 euros. Please contact Pohjola Telephone service: Insurance and Claims Settlement Service, +358 (0) (in English) Internet: yrityspalvelu@pohjola.fi 6