The law clearly regulates what is not always comprehensible for the layperson
Unpleasant when it happens. But when it happens, it's beneficial to know how it works. We're talking about hospitalization. How does it work? Who has to be informed and above all: Who pays the hospital bill? Many questions. Some people feel overburdened. And, since no insurance expert has ever fallen from the sky, we have compiled some useful information on this topic for you.
From a purely insurance-related point of view, there are only two reasons why a hospital stay is necessary: Either because of an accident or as a result of an illness.
Let us first deal with the "accident". The term "accident" is often used colloquially, even though it is not really an accident from a purely legal point of view. In Switzerland, the term "accident" is clearly defined in the Federal Law on the General Part of Social Insurance Law (ATSG). Article 4 states:
So far - so good. However, if one of the above characteristics is not fulfilled, it is not an accident and the event is considered an illness for insurance purposes.
From a legal point of view an illness is paraphrased as follows:
Not infrequently, discussions arise between patients and insurers as not every fact or feature is always clearly understood. There are also differences and uncertainties when it comes to the question of which insurance company pays in the end.
While employees are insured in the event of an accident through the employer's compulsory accident insurance in accordance with the UVG, illnesses are insured through the health insurance, which is also compulsory but usually privately financed.
From a purely financial point of view, it is advantageous for most employees if the event that occurs is an accident, as in the case of an accident there is no deductible and no health insurance franchise, which have to be paid out of the employee's own pocket in case of an illness.
Let's take the following example:
I walk down the stairs carrying a cardboard box. I miss a step, trip and fall. When I fall, I break my arm by hitting the bottom step of the stairs. The definition of an accident is fulfilled here. I have a sudden, unintended impact of an unusual, external factor (the bottom step of the stairs) on my body. The medical and hospital costs are therefore borne by the employer's compulsory accident insurance (UVG).
In the event of an operation, the nursing facility will request a cost guarantee in advance. It is also quite possible that the clinic already requires a cost approval for the stay itself and requests this from the UVG insurer. After reviewing the case, the insurer will issue the cost approval and the costs incurred will be reimbursed by the UVG insurer.
We have a different starting position in the case (which actually happened and was rejected as an accident by the insurer SUVA), in which an employee climbed down from a jumping box while playing football and then twisted his knee. Climbing down from a box is not an everyday activity, but it is a normal movement without increased danger. There was no damaging influence of an unusual, external factor on the body. The person did not trip, slip or fall. In insurance terms, the case must therefore be treated as an "illness".
Financially, things get really messy when a person who is presumed to have suffered an accident has an operation in a private clinic, assuming that the employer's accident insurer will cover the costs. However, if the accident insurer has not yet confirmed the case and, after clarifying the circumstances, comes to the conclusion that it is an "illness", the costs fall back on the health insurance. If there is no corresponding supplementary hospital insurance cover, the person can be left with very high costs and has to pay for them himself. It is therefore worthwhile to obtain the corresponding cost approvals well in advance.
The greatest difficulties of delimitation arise with the criterion of the unusual nature of the external factor. The event or the effect must be unusual. Unusualness is affirmed if the external factor is no longer within the scope of the everyday life of the accident victim according to an objective standard, which is everyday and usual for the respective area of life.
There are numerous court decisions as to whether the individual case is an accident or an illness.
The new accident insurance law came into force on 1 January 2017. Likewise, bodily injuries similar to accidents (e.g. broken bones, torn muscles, torn meniscus) are considered accidents, unless they are primarily due to wear and tear or illness. However, the accident insurer must prove this wear and tear or illness. The exceptionality factor was abolished with the change in the law. In the past, this factor led to many different, sometimes incomprehensible rulings, and has now fortunately been removed.
With regard to the report of the accident, the statements of the first hour apply. As a rule, the first statements about the event are considered to be unbiased and reliable, as opposed to later, more extensive or different accounts.
Stay healthy!
