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Old 09.11.2009, 14:30
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Health insurance refusing to pay for accident

My girlfriend recently fell down while exiting a bus and injured her arm. the next day we went to the emergency room of a hospital where they recorded it as an accident and treated her. She also had to take some follow up physiotherapy.
The total bill was about 800 CHF.

She has insurance from CSS Auxilia with a deductible of 300 CHF. She also took the supplementary insurance. She was an intern with one of the international organisations, and her employer insurance apparently covers only workplace accidents. Now CSS is refusing to pay this as well, and asking us to approach some other insurer, since this falls under LAA.

It is my understanding that the health insurance has to pay for an accident when there is no 3rd party involved. Could someone please shed some light on this. Are there any grounds to contest this refusal from CSS? What are the relevant rules?
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Old 09.11.2009, 14:32
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Re: Health insurance refusing to pay for accident

Do you have additional accident insurance that would cover this, since the employer does not?
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Old 09.11.2009, 14:35
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Re: Health insurance refusing to pay for accident

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Do you have additional accident insurance that would cover this, since the employer does not?
While taking the policy, she specifically requested accident coverage and CSS said that the supplementary insurance would cover it. Was that just marketing?
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Old 10.11.2009, 10:02
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Re: Health insurance refusing to pay for accident

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While taking the policy, she specifically requested accident coverage and CSS said that the supplementary insurance would cover it. Was that just marketing?
I don't think marketing could explain that - normally they try to sell you insurance that you don't need rather than failing to sell you insurance that you do need. However, I would check with your employer. As far as I know the standard accident insurance you get through your employer covers you for all accidents, regardless of whether they are work related. I would be surprised if this is not the case for you.

Personally, I think this system just creates a lot of headaches for people. It did for us, because the two insurances (health and accident) argued for about two years over whether my wife's knee problems were caused by an accident or not, and so were trying to decide who should pay.
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Old 10.11.2009, 10:06
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Re: Health insurance refusing to pay for accident

accident insurance is exactly that - covering accidents.

I've (in no particular order) had accident insurance cover wrist x-rays, a broken leg and some other sport-related accidents.

If you have a job, the employer is duty-bound to cover accidents. And not just in the workplace.

Push back, get in touch with HR at her work and get the coverage details.
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Old 10.11.2009, 11:48
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Re: Health insurance refusing to pay for accident

You can contact the Helath Insurance Ombudsman. They were very helpful when I wrote to them (in English) with questions about my insurance.
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Old 10.11.2009, 11:58
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Re: Health insurance refusing to pay for accident

Indeed your work accident insurance HAS TO cover you also for private accidents provided you work at least x hrs a week (do not remember the number of hrs but if your girlfriend is working full time she is definitely covered)

BUT

She needs to announce the accident within a certain timeframe to the accident insurance.

That is why it is always recommended to announce accidents even if you think nothing of them as if you need to see a doctor later and have not announced it, some insurances refuse to pay.

Also, the health insurance HAS TO insure you for accident UNLESS you prove to them you are insured elsewhere for it as this is not optional.

Net, I am sure she is somewhat covered and speaking to her HR is a good start.

Cheers,
K
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Old 10.11.2009, 11:58
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Re: Health insurance refusing to pay for accident

As others have said the workplace insurance should cover this.
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Old 10.11.2009, 12:17
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Re: Health insurance refusing to pay for accident

The work insurance should cover this even after working hour. I sprain my ankle on my way home and it's consider as accident. My work accident insurance accept it and all my treatment is 100% paid.
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Old 10.11.2009, 12:46
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Re: Health insurance refusing to pay for accident

Employer insures all employees for workplace accidents. Employer arranges insurance for off-site accidents only if employee is regularly employed more than 8 hours per week.

Persons who do not work more than 8 hours a week, at any one employer, must make their own arrangements.

The OP is an "intern". Maybe she is legally not an employee? Does she get a monthly salary and pays social security contributions?
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Old 04.09.2012, 11:06
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Re: Health insurance refusing to pay for accident

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Indeed your work accident insurance HAS TO cover you also for private accidents provided you work at least x hrs a week (do not remember the number of hrs but if your girlfriend is working full time she is definitely covered)

BUT

She needs to announce the accident within a certain timeframe to the accident insurance.

That is why it is always recommended to announce accidents even if you think nothing of them as if you need to see a doctor later and have not announced it, some insurances refuse to pay.

Also, the health insurance HAS TO insure you for accident UNLESS you prove to them you are insured elsewhere for it as this is not optional.

Net, I am sure she is somewhat covered and speaking to her HR is a good start.

Cheers,
K
Sorry to bump an old thread, but this caught my eye. I don't have employer-covered accident insurance because I don't work outside the home. I also don't have an add-on to my existing health insurance, and was never asked by them to prove that I have accident insurance..

This post implies I don't need an add-on and that my regular health insurance covers. But other threads and posts have implied I DO need an add-on to my existing coverage. Which is the case? Is it mandatory or just a really good idea?
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Old 04.09.2012, 11:12
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Re: Health insurance refusing to pay for accident

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Sorry to bump an old thread, but this caught my eye. I don't have employer-covered accident insurance because I don't work outside the home. I also don't have an add-on to my existing health insurance, and was never asked by them to prove that I have accident insurance..

This post implies I don't need an add-on and that my regular health insurance covers. But other threads and posts have implied I DO need an add-on to my existing coverage. Which is the case? Is it mandatory or just a really good idea?
I am pretty sure accident insurance is mandatory (and also a really good idea). http://en.comparis.ch/krankenkassen/...erung-uvg.aspx
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Old 04.09.2012, 11:17
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Re: Health insurance refusing to pay for accident

It's normally included, unless you opt out, which you are only allowed to do if you have employer paid accident insurance.

Tom
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Old 04.09.2012, 11:21
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Re: Health insurance refusing to pay for accident

Accident insurance is mandatory.

If you work more than 8 hours a week your employer pays (it shouldn't matter where you work, i.e. from home or outside your home).

If you are not covered by the mandatory (work) accident insurance, you need to take out coverage from your health insurance.

If you fail to do so, the health insurance can backdate all the premiums for the accident insurance and also charge interest.
http://www.admin.ch/ch/d/sr/832_10/a10.html

Last edited by Mica; 04.09.2012 at 11:23. Reason: typo
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Old 04.09.2012, 11:24
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Re: Health insurance refusing to pay for accident

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The OP is an "intern". Maybe she is legally not an employee? Does she get a monthly salary and pays social security contributions?
'Interns' are always employees from a labor law perspective.
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Old 04.09.2012, 11:25
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Re: Health insurance refusing to pay for accident

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If you work more than 8 hours a week your employer pays (it shouldn't matter where you work, i.e. from home or outside your home).
The employee pays, the employer only arranges for the company's accident insurance.
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Old 04.09.2012, 11:27
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Re: Health insurance refusing to pay for accident

Is the deductible amount (first slice you have to pay) also applicable for accidents, or does one get refunded from the very first franc paid?
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Old 04.09.2012, 11:29
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Re: Health insurance refusing to pay for accident

There is no deductible for accidents.

Tom
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Old 04.09.2012, 11:32
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Re: Health insurance refusing to pay for accident

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There is no deductible for accidents.
Accident coverage by health insurance comes with a deductible – if another person caused the accident, she/he (or her/his insurance) has to pay for the deductible.
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Old 04.09.2012, 11:41
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Re: Health insurance refusing to pay for accident

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I am pretty sure accident insurance is mandatory (and also a really good idea). http://en.comparis.ch/krankenkassen/...erung-uvg.aspx
Thanks!

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It's normally included, unless you opt out, which you are only allowed to do if you have employer paid accident insurance.

Tom
That's where I am confused. I was never given the option to opt in or out. I don't recall them asking me to prove I have employer-paid accident insurance. The monthly bill certainly does not itemize out accident vs. health.

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Accident insurance is mandatory.

If you work more than 8 hours a week your employer pays (it shouldn't matter where you work, i.e. from home or outside your home).

If you are not covered by the mandatory (work) accident insurance, you need to take out coverage from your health insurance.

If you fail to do so, the health insurance can backdate all the premiums for the accident insurance and also charge interest.
http://www.admin.ch/ch/d/sr/832_10/a10.html
Dear me, that makes no sense. If I have had no accidents, why should they be allowed to backdate it and charge interest?

Ok so I guess the next question is...where in my policy should I go hunting to read the fine print for whether or not accident insurance has been included? What is the keyword(s) in German I need to scan for?

And thanks so much for the responses!
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