Accident or illness?

Illness or accident: how to make sure you have the right cover

An accident, a serious medical condition or a death can change everything from one moment to the next. Life events of this kind are stressful, and can even lead to financial difficulties.

Incapacity to work: illness more often the cause

Social insurance usually pays higher benefits for accident than it does for illness. But incapacity to work is more often caused by a medical condition than by an accident. And 90% of deaths before retirement age are due to illness.

That’s why it’s important to know how illness and accident differ, and what benefits those in work will receive in each case. You can then insure yourself and your nearest and dearest against the financial risk.

What constitutes an ac­ci­dent?

From a legal point of view, an accident is always something that happens suddenly and unintentionally, and is caused by external means. If any one of these aspects is missing, the situation isn't classified as an accident. Here are some examples:

• Eveline is cycling to work and is hit by a car. She falls, breaking her arm.
• Cleo is carrying a box up to the attic and misses a step. He falls awkwardly, knocking out a tooth.
• Lisa is hiking and gets bitten by a tick. Any physical complaints and infections that might arise from this tick bite can be seen as accidental consequences.
  

Simple question – difficult answer

But even though the criteria have been legally defined, there are times when the difference between illness and accident is unclear, and the assessment may vary from what is generally expected.

This is not an accident

If Thomas notices an irritating ringing sound in his ears after going to a concert and the doctor diagnosis tinnitus, this isn't an accident. Because Thomas was exposed to loud music for a lengthy period of time, there is no ‘suddenness’ factor at play.

Difference between accident and health insurance

Your employer’s accident insurance pays for accidents that happen in the workplace or during your leisure time, and for occupational diseases. For example, if you’ve been exposed to harmful substances at work.

Private health insurance pays if you fall ill with a medical condition. In Switzerland, everyone is required to have basic insurance. You can take out supplementary insurance to cover more risks. 

What insurance do I have and who pays the costs?

Do you work for at least eight hours a week? Then you’re insured through your employer for occupational and non-occupational accidents. In other words, for incidents that occur in your free time.

A lot of protection for a small amount of money

The self-employed and stay-at-home parents, on the other hand, don't have mandatory insurance cover through an employer. Medical Costs Insurance for Accidents offers a lot of protection for a small amount of money. In addition, you can include accident cover in your basic and supplementary health insurance.

Lower income from continued salary payments

Social insurance covers part of your financial losses – if you become ill or have an accident. But there are big differences in the pensions paid out and in the benefits paid to survivors.

Salary continuation following an accident

Old-age and Survivors' Insurance/Disability Insurance (AHV/IV) pays a daily indemnity for each calendar day, starting from the third day following the accident. If you are left completely unable to work, you will continue to receive 80% of your pensionable salary. The treatment costs will be paid, along with a disability pension or survivors’ benefits in the event of death.

Salary continuation in the event of illness

Anyone can be affected by a serious medical condition. However, if you're no longer able to work due to illness, the AHV/IV will only pay 60 to 70% of your current salary. If an illness leads to death, the survivors will only receive around 50% of the deceased’s final salary.

What your employer pays

By law, employers must continue to pay a salary if the employment relationship has lasted longer than three months or was entered into for more than three months. New hires are entitled to at least 3 weeks’ continued salary payment in the first year of employment. After that, it must be paid for an ‘appropriately longer period’. Alternatively, the employer can also take out daily sickness indemnity insurance.

Tip: Ask your employer about voluntary daily sickness indemnity insurance.

Identify and close gaps

Apart from being stressful, health problems can also leave those affected and their immediate family with financial worries. Social insurance pays higher benefits for an accident, but the risk of falling ill is much higher. And the situation can deteriorate further if an accident turns into an illness – involving chronic pain, for example.

When complications or conditions aren't immediately apparent (‘sequelae’), it can sometimes be difficult to prove that they are related to the accident.

Gaps arise if you fall ill

If you fall ill, there will be a gap between what you currently earn and the money paid by the AHV/IV and your pension fund. So, it makes sense to plan ahead and take out insurance – especially for the risk of illness.