Accident disputed by Occupational Accident Insurance

Banks, Insurances & Third Pillar
1

I had a dental accident and sought dental care. My dentist advised me to report it to my Occupational Accident Insurance (i.e. the accident insurance that I get through my employer). I contacted them with the details of the accident and they wrote back to me stating that they dispute that it was an accident and that they will not cover it.

I’m a foreigner and don’t really understand how the system works. So while it’s plausible that they might be correct, I also believe the insurance company could be just trying to weasel its way out of paying, since probably there is little cost but potential big upside by trying to such a strategy.

So concrete questions to you, dear community member:

  1. Is it normal that they try to avoid paying? Is this just part of the game? Or would they only do this in cases where they really believe it was not an accident.

  2. I have legal insurance. Should I contact them about this case? Or is legal insurance not suitable for this case.
    (2a) My legal insurance is actually with the same company that my Occupational Accident Insurance is with :clown_face: so can I trust that they will act in my interest?

Grateful for any other tips / advice for those who know the system better or have had contact with their Occupational Accident Insurance before :pray:

2

Yes it’s pretty common, you need to be extremely precise when you file your accident report. The law has very specific condition for what counts as accident which does not always match what people think.

(Keywords are: sudden unexpected and external factor when you describe what happened)

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3

I think when it comes to what is covered by accident insurance, what is covered by health insurance, what falls into the grey area and what isn’t actually covered by either, Swiss people stand on the same clueless footing as foreigners.

  1. Same as nabal’s answer above. I wouldn’t take their answer as a sign they’ve done a thorough analysis and come to the genuine conclusion that what happend to you wasn’t an accident as defined by law and their terms and conditions. That doesn’t mean that it was, just that fighting back may have some worth.

  2. It’s always worth phoning them and asking for advice, that part has chances to be covered by your policy (though actual legal procedures may not be). You can be generic and not mention who your occupational accident insurance is. They may catch it, or they may not. At the very least, you’d not end up in a worst situation than you had started in.

Several (many? All?) cantonal lawyers’ associations offer one free short time advice session (at specific times and places in the example of Valais/Wallis). The goal is to identify and inform you of the potential legal avenues that may be worth pursuing (if any). That may offer you more clarity over whether you want to try legal action or you consider it not worth it. To find more about this, you’d have to check the website of your cantonal lawyers’ association (and follow the steps described there).

4

Yes

Oops. Rather yes, but this is exactly the reason why I prefer the legal insurance to be completely separated from all other insurances.

P.S. on the second thought, you should rather act through your employer, which is the customer of the insurance. And actually you can’t contact them directly, it should be handled by the employer.

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6

Second getting some advice. What is considered an accident and what an illness (or in your case not an accident) is sometimes so unclear, that there are court rulings to decide who has to pay. I remember an example about tick bites and other curiosities. Wishing you the best!

7

Tho for dental stuff you’re out of luck if it’s not covered by the accident insurance (if you don’t have separate dental insurance), is anything dental related ever covered by the regular health insurance?

8

Mind sharing what you wrote word for word in the description of the accident (or at least a context of it’s too personal) ? If you fell or something like that and you broke a tooth, that should work, if it’s not a broken tooth then that will be difficult. I was disputed once but in the end they paid

9

Thanks all! I contacted my legal insurance and they asked for all the documents and will get back to me. As part of that i had to reveal to them that it’s the same company. Technically the legal insurance and the occupational insurance are with two sub-companies of the same parent company so hopefully it will be fine. I will report back as things progress

10

I know it’s lame but I’d rather not, as it may result in doxxing myself (I have discussed this irl with people who may recognize things even if i just give a high level explanation)

11

Shouldn’t your employer rather than you contact the insurance?

12

No need to explain it’s totally understandable :slight_smile:

13

You usually tell your employer you had an accident and to open a file with the insurance but you then have to deal with the insurance yourself once this step is done.

14

Yeah exactly this is my understanding (a few people at work i spoke to who had filed accident claims had all done it directly and not through the employer… i don’t know if it perhaps varies between insurance companies / the deals they make with the companies)