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Old 14.08.2015, 11:35
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Accident/Health Insurance Hot Potato

About a month ago I dislocated my shoulder. Now I am dealing with the mess that comes with health insurance companies. Last week I received a letter from the accident insurance claiming they were not liable. My German to date is terrible, but to my ear when I pass it through Google translate they are using weasel words. There's a perfectly accurate word in German to describe the injury (ausrenken) which they aren't using. Treatment required general anesthesia in the emergency room.

I took the letter to my group's secretary who normally should help with such problems but I believe now work will try and just bury it and leave me to fend for myself. Since Swiss laws tend to be highly unique I am hoping y'old English Forum can give some advice.

Letter in German here:

Die Unfallmeldung Ihres Arbeitgebers haben wir erhalten und den Sachverhalt sorgfältig geprüft.

Sie verspürten Schmerzen in der Schulter beim Schwimmen im Rhein -- also im Zusammenhang mit einer normalen Köperbewegung. Die Unfallmeldung Ihres Arbeitsgebers haben wir erhalten und den Sachverhalt sorgfältig geprüft.

Laut Gesetzgebung bedeutet das:

Es handelt sich um keinen Unfall wie er in Art. 4 des Bundesgesetzes über den Allgemeinen Teil des Sozialversicherungsrechts (ATSG) definiert ist: "Unfall ist die plötzliche, nicht beabsichtigte schädigende Einwirkung eines ungewöhnlichen äusseren Faktors auf den menschlichen Körper, die eine Beeinträchtigung der köperlichen oder geistigen Gesundheit oder den Tod zur Folge hat."

Laut ärztlichen Berichten liegt auch keine unfallähnliche Köperschädigung vor, wie sie in Art. 9 Abs. 2 der Verordnung über die Unfallversicherung, UVV, genannt werden (sog. Listenverletzungen sind z. B. Knochenbrüche oder Muskelrisse). Voraussetzung für das Vorliegen einer unfallähnlichen Köperschädigung sind ein unfallähnliches oder ein sinnfälliges Ereignis und das Vorliegen einer Verletzung laut Art. 9 Abs. 2 der Verordnung über die Unfallversicherung (UVV).

In Ihrem Fall wurde eine Listenverletzung diagnostiziert. Das vib Ihnen geschilderte Ereignis stellt jedoch eine alltägliche Lebensverrichtung dar, weshalb die Voraussetzung für einen unfallähnlichen Vorfall bzw. ein sinnfälliges Ereignis nicht erfúllt ist.

Wir enttäuschen Sie ungern, aber die Gesetze bieten keinen gangbaren Weg für die Übernahme von Leistungen. Wichtig für Sie: Sie sich an Ihre Krankenkasse.

Wenn Sie eine Verfügung benötigen, gegen die Sie Einsprache erheben können, informieren Sie uns bitte innert zwei Wochen und geben uns Name, Adresse, und die Mitgliedsnummer Ihrer Krankenkasse an.

Bitte beachten Sie: Eine Kopie dieses Schreibens geht an Ihren Arbeitgeber.
Wir wünschen Ihnen alles Gute und hoffen, dass Sie unsere Entscheidung nachvollziehen können.

I guess my next step is to contact my health insurance company, but I have no invoices or other documentation. Basic questions for the peanut gallery:

1.) Can I demand correspondence in French instead of German?

2.) My inference in other countries would be that this should lead to a fight between the accident and health insurance as to whom will pay. Is this correct? I.e. should I go to my health insurer and point out this letter and what I see as factual laziness?

3.) The surgeons want to operate to reduce the likelihood of re-occurrence, which I agree is necessary. However, who covers the costs and absence from work? I am wondering if I can use vacation time to cover the convalescence?

Any other pitfalls I need to be aware of?
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Old 14.08.2015, 13:11
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Re: Accident/Health Insurance Hot Potato

The accident insurance say this was no accident, as there was no sudden external force applied to your body.

You can send the hospital bills to your health insurance company.

If you need an operation, your company will pay for you to convalesce.
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Old 14.08.2015, 14:28
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Re: Accident/Health Insurance Hot Potato

As Sbrinz says, send the bills to your health insurance. Unfortunately you'll get a little less back from the health insurance than you would from accident insurance as accident insurance doesn't have a co-pay amount ("Selbstbehalt"), but there's nothing you can do about that.
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Old 14.08.2015, 20:24
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Re: Accident/Health Insurance Hot Potato

There's no need to worry. If your accident insurance doesn't cover, as already said, send your bills to your health insurance (or better, ask your accident insurance to do so, so that nothing gets lost) and they'll take care of it. If your health insurance also say they don't have to pay, they will discuss this with your accident insurance company and the companies will come to a solution which will pay for your treatment.

You will be fine.

Take care!
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Old 14.08.2015, 20:33
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Re: Accident/Health Insurance Hot Potato

the receipts the hospital will reproduce for you without too much fuss. The comments are right - if there was no external force then its not an accident, so you claim it as maladie with your health insurance company, tell them all the details and if they are a good one they may contact the hospital to get the details, if they are cheapo like Assura you'll have to do the legwork yourselves, but the doctors and hospitals are used to that sort of request.

if your on 2.5k deductible then remember the first part of it comes out of your own pocket.
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Old 14.08.2015, 21:39
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Re: Accident/Health Insurance Hot Potato

You might find this (somewhat old) thread of interest. There's even a mention of a guy who dislocated his shoulder at a ski resort and was also refused accident cover due to a pre-existing condition.

What is an "accident"?
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Old 14.08.2015, 21:51
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Re: Accident/Health Insurance Hot Potato

From the letter, it doesn't seem as you actually dislocated your shoulder at all btw- they talk about 'pain' not dislocation, or have I missed something?

Yes, franchise + 10% of total cost.
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Old 14.08.2015, 22:03
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Re: Accident/Health Insurance Hot Potato

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Yes, franchise + 10% of total cost.
Up to a maximum, yes?
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Old 14.08.2015, 22:06
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Re: Accident/Health Insurance Hot Potato

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Up to a maximum, yes?
CHF 700.-/year and only with health insurance. With accident insurance, there is no retention fee.
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Old 14.08.2015, 23:00
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Re: Accident/Health Insurance Hot Potato

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CHF 700.-/year and only with health insurance. With accident insurance, there is no retention fee.
But if you're not employed and have your accident insurance via the health insurance then your normal franchise applies no?
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Old 14.08.2015, 23:08
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Re: Accident/Health Insurance Hot Potato

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But if you're not employed and have your accident insurance via the health insurance then your normal franchise applies no?
No, since your health insurance company is doing the job of an accident insurance company and as such neither deductible nor retention fee apply. You only pay CHF 700/year retention fee and whichever deductible you chose for health insurance related issues, not for accidents, no matter who covers them.

Franchise=deductible (CHF 300/500/1000/1500/2000/2500), not Selbstbehalt/Retention fee (max CHF 700).
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Old 14.08.2015, 23:22
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Re: Accident/Health Insurance Hot Potato

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No, since your health insurance company is doing the job of an accident insurance company and as such neither deductible nor retention fee apply. You only pay CHF 700/year retention fee and whichever deductible you chose for health insurance related issues, not for accidents, no matter who covers them.

Franchise=deductible (CHF 300/500/1000/1500/2000/2500), not Selbstbehalt/Retention fee (max CHF 700).
In that case both ourselves and friends of ours were both incorrectly billed for the 10% retention fee for accidents last year. Different insurance companies too.

I shall have a closer look at the policy tomorrow.
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Old 14.08.2015, 23:23
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Re: Accident/Health Insurance Hot Potato

Interesting- do report back BM when you have checked and maybe talked to your insurance.
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Old 14.08.2015, 23:58
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Re: Accident/Health Insurance Hot Potato

Belgianmum is right, if your accident insurance is not through an employer then it's subject to deductible and co-pay just like an illness claim.

More info here (in German, sorry) from the Beobachter:
http://www.beobachter.ch/geld-sicher...se-bei-unfall/
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Old 15.08.2015, 00:01
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Re: Accident/Health Insurance Hot Potato

What isn't clear from the OP's post is whether it was an accident or not.

It is possible that this was not made clear in the original claim, but should be clarified before going to the health insurance company. Put it this way, it is unusual to dislocate a shoulder without some form of trauma/external force.

Secondly, insurance companies do make mistakes, or if you wish to be less charitable try to pull one over clients, so again, I would seek further clarification before proceeding. Also get someone from HR to support you in this, as if your German isn't great, are you sure that you completed the claim fully and correctly?
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Old 16.08.2015, 14:45
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Re: Accident/Health Insurance Hot Potato

SUVA accident notifications are filed (and usually, filled out) by the employer.

The finding is mentioned, at least from the SUVA point of view. There was no external factor involved, nor was there some event like, for instance, a walker tripping over his own feet and damaging his ankle when preventing a fall. Thus it's not covered by SUVA.
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Old 16.08.2015, 16:04
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Re: Accident/Health Insurance Hot Potato

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SUVA accident notifications are filed (and usually, filled out) by the employer.

The finding is mentioned, at least from the SUVA point of view. There was no external factor involved, nor was there some event like, for instance, a walker tripping over his own feet and damaging his ankle when preventing a fall. Thus it's not covered by SUVA.
SUVA said the same when I had an arthroscopy on my knee last year. The damage reported (by the surgeon) was inconsistent with a sudden injury, and in fact they were right - I'd had a number of minor 'tweaks' which were getting progressively worse, and were caused mainly misalignment of the leg/knee.

So I'm now sitting here in RennbahnKlinik, Muttenz, six days after having surgery to realign the leg (Opening Wedge High Tibial Osteotomy), to repair cartilage damage to the top of the tibia (Microfracture) , and to replace the ACL that was broken ~14 years ago in an accident.

I'm waiting to see what happens with the bills - clearly the ACL was done an accident, but not the one I reported when I started this process, which was really just the latest time I'd done something to make me aware of the damage, and although I know exactly when I tore the ACL, and saw a doctor (who just told me to take it easy for a day or two, nothing major damaged) it was around 13 years ago and not reported to SUVA.

As I say, I'll wait and see. In any event I'll be over my 1500chf franchise for this year, so the cost difference to me should be just the 10% retention, but it's annoying to note that I could have handled it differently had I known what was actually wrong.
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