Go Back   English Forum Switzerland > Help & tips > Insurance  
Reply
 
Thread Tools Display Modes
  #1  
Old 20.01.2020, 15:52
Newbie 1st class
 
Join Date: Nov 2013
Location: Zurich
Posts: 11
Groaned at 0 Times in 0 Posts
Thanked 3 Times in 2 Posts
reza_p_o has no particular reputation at present
Rejection of accident insurance coverage after a year

I had an accident in July 2018, and the accident insurance (through my employer) agreed to cover the incident. During this time, they have continuously paid for my doctor visits, medication, physiotherapy, chiropractic, etc with no problem.

This week however, they sent me a letter saying that they have reevaluated my case by external doctors, and concluded that they should have stopped the coverage 3 months after the incident (Oct. 2018). They also mention that they will not reclaim the paid bills, but will not pay the outstanding ones (those before they notified me) or any new ones.

Assuming that I am covered by the accident insurance, I have not followed the protocol of my health insurance over this time (I had a pharmed plan with Assura). For example, I didn't get the medication from Assura designated pharmacies, I went to a specialist without a referral from a family doctor and also visited an Osteopath.

Now here is my question:
Can the accident insurance stop paying the bills retrospectively? Is there a clause in the law that allows them to do so?
Do I have any grounds in asking them to pay the previous bills that are not covered by my health insurance?
Reply With Quote
  #2  
Old 20.01.2020, 15:58
NotAllThere's Avatar
Forum Legend
 
Join Date: Oct 2008
Location: Baselland
Posts: 13,273
Groaned at 216 Times in 191 Posts
Thanked 19,363 Times in 7,881 Posts
NotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Sounds a bit odd. What are their grounds for rejection?
Reply With Quote
The following 3 users would like to thank NotAllThere for this useful post:
  #3  
Old 20.01.2020, 16:03
Guest
 
Posts: n/a
Re: Rejection of accident insurance coverage after a year

Did you change jobs or were made unemployed during that time? If they "stopped the coverage", it would sort of make sense if you moved to a new company which used a different insurer for its employees, although maybe they continue ongoing care for an individual after they've left the company?
Reply With Quote
  #4  
Old 20.01.2020, 17:11
Newbie 1st class
 
Join Date: Nov 2013
Location: Zurich
Posts: 11
Groaned at 0 Times in 0 Posts
Thanked 3 Times in 2 Posts
reza_p_o has no particular reputation at present
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
Sounds a bit odd. What are their grounds for rejection?
They say the present pain is not anymore because of the accident, and the accident effect should have gone away in 3 months.

Quote:
View Post
Did you change jobs or were made unemployed during that time?
Yes, I did but as far as I know you cannot carry a previous accident to a new accident insurer. The accident insurer at the time of incident should continue paying as long as it is justified.

Right now my question is not why they have done this, but whether they can stop paying retrospectively!
Reply With Quote
The following 2 users would like to thank reza_p_o for this useful post:
  #5  
Old 20.01.2020, 17:42
curley's Avatar
Forum Legend
 
Join Date: Oct 2006
Location: canton ZH
Posts: 12,699
Groaned at 206 Times in 171 Posts
Thanked 14,539 Times in 7,508 Posts
curley has a reputation beyond reputecurley has a reputation beyond reputecurley has a reputation beyond reputecurley has a reputation beyond reputecurley has a reputation beyond reputecurley has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
They say the present pain is not anymore because of the accident, and the accident effect should have gone away in 3 months.


Yes, I did but as far as I know you cannot carry a previous accident to a new accident insurer. The accident insurer at the time of incident should continue paying as long as it is justified.

Right now my question is not why they have done this, but whether they can stop paying retrospectively!
Normal procedure would be, the insurer send you to see a "Vertrauensarzt" (fiduciary doctor). After that such a decision can be made. And usually is

They can not decide on your current state without a doctor having checked you out.
Reply With Quote
The following 2 users would like to thank curley for this useful post:
  #6  
Old 20.01.2020, 17:46
Jim2007's Avatar
Forum Legend
 
Join Date: Jun 2006
Location: Kt. Bern
Posts: 4,508
Groaned at 217 Times in 171 Posts
Thanked 7,421 Times in 3,283 Posts
Jim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
Right now my question is not why they have done this, but whether they can stop paying retrospectively!
You need to start by looking at the policy and go from there. Do you have a copy of the policy you can check?
Reply With Quote
  #7  
Old 20.01.2020, 17:53
Island Monkey's Avatar
Forum Legend
 
Join Date: Mar 2008
Location: Wallis
Posts: 5,748
Groaned at 95 Times in 60 Posts
Thanked 6,305 Times in 2,888 Posts
Island Monkey has a reputation beyond reputeIsland Monkey has a reputation beyond reputeIsland Monkey has a reputation beyond reputeIsland Monkey has a reputation beyond reputeIsland Monkey has a reputation beyond reputeIsland Monkey has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
They say the present pain is not anymore because of the accident, and the accident effect should have gone away in 3 months.


Yes, I did but as far as I know you cannot carry a previous accident to a new accident insurer. The accident insurer at the time of incident should continue paying as long as it is justified.

Right now my question is not why they have done this, but whether they can stop paying retrospectively!
I would definitely fight for them to pay all treatment that happened before they informed you of the fact that they are no longer willing to pay.
Reply With Quote
The following 2 users would like to thank Island Monkey for this useful post:
  #8  
Old 20.01.2020, 18:18
Junior Member
 
Join Date: Dec 2019
Location: Luzern
Posts: 31
Groaned at 6 Times in 3 Posts
Thanked 25 Times in 12 Posts
Adidas has no particular reputation at present
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
You need to start by looking at the policy and go from there. Do you have a copy of the policy you can check?
No, mandatory accidents insurance is regulated by law and not by contracts or insurance policies.

Back to OP's problem: retroactive refusal of insurance cover is only permissible in a few cases. I suspect foul play on the part of the insurance company. Did they give you a deadline to appeal their decision?
Reply With Quote
The following 6 users would like to thank Adidas for this useful post:
  #9  
Old 20.01.2020, 18:27
st2lemans's Avatar
Forum Legend
 
Join Date: Dec 2010
Location: Lugano
Posts: 31,607
Groaned at 2,354 Times in 1,712 Posts
Thanked 38,416 Times in 18,128 Posts
st2lemans has a reputation beyond reputest2lemans has a reputation beyond reputest2lemans has a reputation beyond reputest2lemans has a reputation beyond reputest2lemans has a reputation beyond reputest2lemans has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Do you have legal insurance? If so, use it!

Tom
Reply With Quote
The following 3 users would like to thank st2lemans for this useful post:
  #10  
Old 20.01.2020, 18:31
Junior Member
 
Join Date: Dec 2019
Location: Luzern
Posts: 31
Groaned at 6 Times in 3 Posts
Thanked 25 Times in 12 Posts
Adidas has no particular reputation at present
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
Do you have legal insurance? If so, use it!

Tom
This a 1000 times. Most legal insurances cover UVG disputes. Even without insurance you might find a lawyer who appeals for you free of charge.
Reply With Quote
This user would like to thank Adidas for this useful post:
  #11  
Old 20.01.2020, 19:19
NotAllThere's Avatar
Forum Legend
 
Join Date: Oct 2008
Location: Baselland
Posts: 13,273
Groaned at 216 Times in 191 Posts
Thanked 19,363 Times in 7,881 Posts
NotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond reputeNotAllThere has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
Right now my question is not why they have done this, but whether they can stop paying retrospectively!
The short answer to your question is yes, probably. But it depends on why. Which is why I asked you what the grounds they gave were.
Quote:
They say the present pain is not anymore because of the accident, and the accident effect should have gone away in 3 months.
"Should have". Seems a bit dodgy really. What matters is whether the effects of the accident have gone away, not what the medics would have expected.

It seems to be very unreasonable. And even if their grounds are solid, their mistake shouldn't leave you out of pocket. They're clearly not suggesting wrong-doing on your part. I would definitely fight this, but legal advice would tell you the best strategy.

Is your insurance SUVA? We had some issues with them last year refusing initially a claim that they in law had no choice but to cough up for. We pointed out the relevant OR, and they reversed their decision.
__________________
Down with racism. Long live miscegenation!
Reply With Quote
The following 2 users would like to thank NotAllThere for this useful post:
  #12  
Old 20.01.2020, 21:09
Jim2007's Avatar
Forum Legend
 
Join Date: Jun 2006
Location: Kt. Bern
Posts: 4,508
Groaned at 217 Times in 171 Posts
Thanked 7,421 Times in 3,283 Posts
Jim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
No, mandatory accidents insurance is regulated by law and not by contracts or insurance policies.
Except in certain circumstances it can be voided.
Reply With Quote
  #13  
Old 20.01.2020, 21:14
MusicChick's Avatar
modified, reprogrammed and doctored˛
 
Join Date: Feb 2008
Location: La Cote
Posts: 17,314
Groaned at 395 Times in 271 Posts
Thanked 20,033 Times in 10,427 Posts
MusicChick has a reputation beyond reputeMusicChick has a reputation beyond reputeMusicChick has a reputation beyond reputeMusicChick has a reputation beyond reputeMusicChick has a reputation beyond reputeMusicChick has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Isn't there an ombudsman here for these kinds of shady practices?
Reply With Quote
This user would like to thank MusicChick for this useful post:
  #14  
Old 20.01.2020, 21:47
roegner's Avatar
Moderately Dutch
 
Join Date: May 2011
Location: Zurich
Posts: 11,079
Groaned at 366 Times in 307 Posts
Thanked 13,937 Times in 6,500 Posts
roegner has a reputation beyond reputeroegner has a reputation beyond reputeroegner has a reputation beyond reputeroegner has a reputation beyond reputeroegner has a reputation beyond reputeroegner has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
Isn't there an ombudsman here for these kinds of shady practices?
Not enough information to know if it is shady. But I am sure there is an ombudsman yes
Reply With Quote
This user would like to thank roegner for this useful post:
  #15  
Old 20.01.2020, 21:55
MusicChick's Avatar
modified, reprogrammed and doctored˛
 
Join Date: Feb 2008
Location: La Cote
Posts: 17,314
Groaned at 395 Times in 271 Posts
Thanked 20,033 Times in 10,427 Posts
MusicChick has a reputation beyond reputeMusicChick has a reputation beyond reputeMusicChick has a reputation beyond reputeMusicChick has a reputation beyond reputeMusicChick has a reputation beyond reputeMusicChick has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Yes, I know there is. And the contact info is searchable online. Good luck OP..
Reply With Quote
This user would like to thank MusicChick for this useful post:
  #16  
Old 21.01.2020, 08:34
Forum Legend
 
Join Date: May 2007
Location: Tessin
Posts: 6,356
Groaned at 124 Times in 91 Posts
Thanked 7,593 Times in 3,559 Posts
Mrs. Doolittle has a reputation beyond reputeMrs. Doolittle has a reputation beyond reputeMrs. Doolittle has a reputation beyond reputeMrs. Doolittle has a reputation beyond reputeMrs. Doolittle has a reputation beyond reputeMrs. Doolittle has a reputation beyond repute
Re: Rejection of accident insurance coverage after a year

Did your doctor write the insurance company telling them you would be okay by a certain date?

Doctors are often asked for an update which perhaps you, as the insured, were not made aware of. The insurance company may have this information hence the reason for their decision.
Reply With Quote
The following 3 users would like to thank Mrs. Doolittle for this useful post:
  #17  
Old 21.01.2020, 11:56
Newbie 1st class
 
Join Date: Nov 2013
Location: Zurich
Posts: 11
Groaned at 0 Times in 0 Posts
Thanked 3 Times in 2 Posts
reza_p_o has no particular reputation at present
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
retroactive refusal of insurance cover is only permissible in a few cases.
Thanks!
Could you please provide a pointer to the law that says this, if possible?
And yes, I have until 10.02.2020 to object to this.
Reply With Quote
  #18  
Old 21.01.2020, 12:11
Senior Member
 
Join Date: Nov 2006
Location: Zurich
Posts: 258
Groaned at 3 Times in 3 Posts
Thanked 56 Times in 47 Posts
Greenhill has earned some respectGreenhill has earned some respect
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
No, mandatory accidents insurance is regulated by law and not by contracts or insurance policies.

Back to OP's problem: retroactive refusal of insurance cover is only permissible in a few cases. I suspect foul play on the part of the insurance company. Did they give you a deadline to appeal their decision?

Insurance companies are equipped with lawyers and experts to support there version. My case was rejected after a year where insurance company decided that I have to pay back all the cost including a knee operation. I had to involve Rechtschutz lawyers and they negotiated a deal where insurance company. My advice is to get a lawyer if the cost is too high.
Reply With Quote
This user would like to thank Greenhill for this useful post:
  #19  
Old 21.01.2020, 13:16
Junior Member
 
Join Date: Dec 2019
Location: Luzern
Posts: 31
Groaned at 6 Times in 3 Posts
Thanked 25 Times in 12 Posts
Adidas has no particular reputation at present
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
Thanks!
Could you please provide a pointer to the law that says this, if possible?
And yes, I have until 10.02.2020 to object to this.
The law should be the Art. 25 (reimbursement) and Art. 53 (revision and reconsideration) ATSG, but I think that your problem is rather a jurisprudential notion.

If I were you, I would proceed as follows:
I would contact the accident insurance company and request payment of any unpaid expenses prior to their decision. Chances are that the insurer will cover these unpaid expenses.

If this does not work, I would contact the health insurance company to see if they do not wish to oppose the decision.

Finally, I would contact a lawyer or legal protection insurance, if available.
Reply With Quote
The following 4 users would like to thank Adidas for this useful post:
  #20  
Old 21.01.2020, 13:19
Junior Member
 
Join Date: Dec 2019
Location: Luzern
Posts: 31
Groaned at 6 Times in 3 Posts
Thanked 25 Times in 12 Posts
Adidas has no particular reputation at present
Re: Rejection of accident insurance coverage after a year

Quote:
View Post
Insurance companies are equipped with lawyers and experts to support there version. My case was rejected after a year where insurance company decided that I have to pay back all the cost including a knee operation. I had to involve Rechtschutz lawyers and they negotiated a deal where insurance company. My advice is to get a lawyer if the cost is too high.
This is why OP should contact his health insurance. If the expenses are high and the health insurance has to step him. Chances are that they will oppose the decision of the accident insurance. Than you have the lawyers of both sides fighting each other. Free of charge for OP.
Reply With Quote
The following 3 users would like to thank Adidas for this useful post:
Reply

Tags
accident inssurance, claim, health insurance




Currently Active Users Viewing This Thread: 1 (0 members and 1 guests)
 
Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Trackbacks are Off
Pingbacks are Off
Refbacks are Off


Similar Threads
Thread Thread Starter Forum Replies Last Post
Accident on maternity leave /accident insurance question swissviking Insurance 14 09.01.2020 22:05
New insurance coverage, need to cancel old coverage ChocolateSoyMilk Insurance 5 19.05.2019 21:53
Rejection of Supplementary Insurance is1107 Insurance 15 14.02.2015 08:19
Accident insurance coverage when unemployed Corbets Insurance 9 16.06.2014 14:11
Question about extent of SUVA accident coverage, specifically damaged possessions Spellbound Daily life 16 13.06.2013 09:34


All times are GMT +2. The time now is 18:56.


Powered by vBulletin® Version 3.8.4
Copyright ©2000 - 2021, Jelsoft Enterprises Ltd.
LinkBacks Enabled by vBSEO 3.1.0