Hi guys, so i'm in a tricky situation. I had an operation in December that was originally classed as an accident, but in January the accident insurance claimed it was not an accident and refused payment. (I am disputing this but thats a seperate issue)

I have been off work for almost 3 months recovering and gave my Arztzeugnis to my work in January. Anyway, whilst the accident insurance refusal is being disputed I have been receiving the medical bills, which are counting towards my krankenkasse franchise. The ombudsman dealing with my dispute case advised that I ask my boss to claim the sick pay through KTG, however when I spoke to him he got funny because it meant having to pay the waiting period, and when I pushed him on it he said he would speak to the KTG insurance.

Anyway, he came back to me saying that the KTG insurance wouldn't pay because my Arztzeugnis has accident written on it instead of sickness. So at the moment I havent received any money during my time off from work.

I'm not sure whether my boss is lying and never spoke to the KTG or not, but i'm wondering what rights I have and what the best course of action is. Does anyone have experience of this situation or know how best to handle it?

Accident pays for off time due to accident, and vice versa, so until it's sorted, expect neither to pay.

Tom

This seems kind of crazy to me, if they are able to send the medical bills through to you and expect payment straight away. How can they justify withholding payments?

I read about the 'right to continued payment' ORT324a and wondered why this doesn't come into affect. Surely the employer should still be paying out for at least the statutory period regardless of which insurance pays and when?

Not sure who "they" is now.
I'm sure this situation has been discussed before. Maybe search the forum (using google). I would suppose the accident insurance needs to talk to the employer and the employer sickness insurance to inform them they need to pay out. I think but am not sure there's no waiting period for accident insurance salary payout but there is for sickness insurance. You might also need/be forced to apply for long term sickness help. I forget what it's called now but whichever insurance will inform you about it.

'They' in my last comment meant the insurance companies.

I tried searching for this through the forum but didn't find a lot of information that related to my problem.. any that I did find were quite old so I wasn't sure how relevant they were anymore.

The complication is that for now the Ombudsman for insurance is dealing with the accident insurance dispute which means that I haven't reached the formal stage of refusal, and so i'm kind of left in limbo waiting and as i'm waiting my money to hire a lawyer, if it's needed or even just get by is running lower and lower

Maybe try the ombudsman?

https://www.ch.ch/en/ombudsman-service/

Thanks newtoswitz, i'm working with the Ombudsman to help dispute the accident insurance refusal but didn't realise there was a directory for different sectors!

Sorry yes, I meant to say "other ombudsman" - as you see there's a whole bunch.

Hopefully they don't also go down the route of passing you off to the other one...

But was it an accident, or an illness? That is the key.

That is the problem.. I explained it all in this post:

https://www.englishforum.ch/insuranc...-who-pays.html

but basically that is what I am trying to dispute with the accident insurance as the need for an operation was triggered by an accident I had over a year ago, but the insurance claims there were signs of an older injury that created the problems.

Sometimes what helps to un-block such a situation is to send the outline of the information to all the parties at once, in a very polite, non-accusatory letter. It could be that someone, somewhere, is missing a piece of the information, without even realising it.

You would need to specify at least:

• Date of commencement of employment
• Full details of employer
• Date of accident
• Whether the accident was at work (Berufsunfall) or outside of work (Nichtberufsunfall)
• Accident number
• Date of surgery
• Date since which you have a doctor's certificate saying you are unfit for work (and the doctor's certificates)
• Name of insurer of the BU, and of the NBU (they may or may not be the same insurer)
• Name of your medical insurance (and whether or not you have this through your employer)
• Date upon which you last received a salary
• All your salary slips showing that salary, and the subsequent monthly slips showing no salary

Something along these lines, perhaps.

Good Day,
This letter is addressed simultaneously to:
employername, BU, NBU, medical insurance.

The people involved in this case:
at employername: Manager Mr Name, and in the HR department Ms Name
at the BU and NBU (same company), Ms Name and Mr Name, in the department called Name
at the Krankenkasse, Mr Name and Mr Name in the department called Name.

In terms of Swiss law, as an employee, I am entitled to ongoing salary payments while unable, according to a doctor, to work, and cover for accidents (by the BU and NBU) and also for illness (from the Krankenkasse). However, the last salary I received was on DATE. This is a causing me great distress. (If you are supporting family members, add that point, here.)

The purpose of this letter is to ensure that all the parties involved have all the information necessary to process my claim. I enclose (full list of documents, as above, including "issued by whom" and "date of issue").

Kindly let me know, for your institution, whether you have all the documentation you need, or are missing any information, to enable to process this matter.

Please advise me of the next steps, as you see them, that are needed, and by whom, so that my salary payments can continue.

Such a letter may have the real effect of putting some missing parts of the puzzle together. It may also have a psychological effect of making someone who has not been properly doing what they should have been doing, wake up and do their job, or teach you how it works.

Source: experience.