Statutory accident insurance for employees is governed by the Swiss Federal Law on Accident Insurance (LAI). Self-employed persons can take out this insurance voluntarily.
Insurance for daily sickness benefits under private law is governed by the Swiss Federal Law on Insurance Contracts (LIC).
And finally, compulsory health care insurance is governed by the Swiss Federal law on Health Insurance (KVG).
Both the accident and illness concepts, which are binding for the LAI and KVG, are defined in the General Part of Social Insurance Law (GPSL).
The law defines an accident as the "sudden, unintended damaging effect of an exceptional external factor on the human body, resulting in an impairment of physical, emotional or psychological health or death."
The concept of illness, on the other hand, is described as "any impairment of physical, emotional or psychological health, which is not the result of an accident and which requires a medical examination or treatment, or results in the inability to work."
Private health or accident insurance companies usually refer to these definitions in their policies.
The employer's obligation to continue to pay wages in the case of illness is governed by Article 324a of the Swiss Code of Obligations (CO). The provision stipulates that the employer must only continue to pay wages once the employment relationship has lasted more than three months or if the employment relationship was entered into for more than three months. The law only specifically regulates the duration of this obligation for the first year of service: the obligation to continue to pay wages lasts three weeks. From the second year of service onwards, it exists "for an appropriate longer period of time". In order to make this wording more precise, various scales have been used in practice (Bern, Basel and Zurich scale).
The obligation to continue to pay wages can be replaced by an equivalent provision (Art. 324a para. 4 Swiss Code of Obligations). It is thus possible for employers to exempt themselves from this obligation, for example by taking out insurance for daily sickness benefits with adequate insurance cover.
In the area of accident insurance according to LAI, the insurance company that already paid for the initial treatment must in principle pay for the treatment costs of long-term effects or relapses. However, depending on the specific constellation, a different distribution of obligations to pay indemnity is also possible.
An accident is deemed to be the "sudden, unintended damaging effect of an extraordinary external factor". Theses examples, constitute an accident:
Events such as a fracture or torn tendon often happen without an "external effect" - as required by law. Nevertheless, they have an accident-like character. The law provides some clarity: since January 1, 2017, it has stipulated that subsequent physical injuries are considered to be the result of an accident and are therefore covered by the statutory accident insurance. Exception: the injury is mainly due to wear and tear or illness. The definition of accident does not apply in the these cases.
As a rule, all health impairments that do not meet the legal definition of an accident and do not belong to the accident-like events listed in the law are considered illnesses.
An occupational illness is a special case of illness. As such, it does not meet the definition of an accident, but is still insured under the Swiss Federal Law on Accident Insurance (LAI). An occupational illness exists if it is "caused exclusively or predominantly by harmful substances or certain work in the course of the occupational activity". Furthermore, other illnesses that can be proven to have been "caused exclusively or predominantly by the occupational activity" also constitute occupational illnesses.
The question of whether an event constitutes an accident or an illness is a recurring concern for insurance companies, lawyers and courts. The following three examples demonstrate that the analysis is complex and can turn out differently in individual cases than generally assumed.
The law describes the term accident as a the sudden, unintended damaging effect effect of an extraordinary external factor on the human body. A bee sting is considered an accident for insurance purposes. Possible infections arising from it can also be considered consequences of an accident and are therefore covered by accident insurance.
As a rule, inguinal hernias are illness-related conditions. Inguinal hernias are a hernia in the abdominal wall, often caused by a congenital weakness of the connective tissue or obesity and increased pressure in the abdomen. Pregnancy can also increase the risk of an inguinal hernia. Inguinal hernias are usually considered an illness and only in rare exceptional cases the result of an accident.
Hanna visits a concert. On returning home, she notices an annoying ringing in her ear, which continues the next day. The doctor diagnoses tinnitus. The definition of an accident is not fulfilled here, as the suddenness is missing. Therefore, it is not an accident but an illness.
Hanna visits a concert at which some visitors light fireworks without permission. One of these fireworks explodes loudly right next to Hanna. The doctor diagnoses an acoustic trauma. The definition of an accident is fulfilled here (sudden, unintended, exceptional external factor, damaging effect), which is why it is considered an accident.
