Cross-border workers – non-occupational accidents: changes in reimbursement policy

cross-border workers-non-professional-accidents
 
As of 1 January 2021, hardcopy forms are being gradually replaced by a system of electronic exchanges between social security institutions in the EU countries and Switzerland. This evolution has had an impact on the reimbursement of non-occupational accidents where the remaining costs at the expense of the person insured can now be as high as 30% of the expenses involved.

Accident or illness, that is the question!

If a cross-border worker has a non-occupational accident and is cared for in Switzerland, they will be covered and reimbursed for care expenses by the obligatory accident insurance (LAA) in conformity with Swiss legislation (100% reimbursed according to the Swiss base rate).
 
On the other hand, if they are treated in France, they will be reimbursed according to French legislation. However, in France as in the other EU countries, non-occupational accidents are covered by health insurance and not accident insurance. The consequence of this is that the coverage of costs is substantially lower than in Switzerland as only 70% of follow-up medical care is reimbursed. The cross-border worker must therefore cover the remaining 30% out of their own pocket!
 
Because of these major differences in the way claims are treated, non-occupational accidents cannot be managed by the new electronic system of data exchange. The Swiss accident insurance has set up a specific form – the S2 – which is transmitted to the person insured and the French Social Security (see the table below).

Non-occupational accidents treated in France

 
Prior to 1 January 2021 As of 1 January 2021
  • Form E 123 or DA1 issued by authorised accident insurances and transmitted to the Social Security. An attestation is provided to the person insure
  • Or an LAA form and pharmacy prescription by non-authorised insurances
     
 
  • Form S2 issued by the accident insurance and transmitted to the person insured and the Social Security
  • The invoice is paid by the Social Security
  • Request for reimbursement by the Social Security to the LAMal institution
  • Invoice sent by the LAMal institution to the Swiss accident insurance
Reimbursement of the costs is covered by the Swiss accident insurance on the basis of the French legislation on occupational accidents (even in the case of non-occupational accidents). Reimbursement is made on the French health insurance basis, meaning approximately 70% of the costs. Which leaves a remainder of some 30% at the expense of the person insured.

 Source : Frontalier Magazine N°153 – Feb. 21

 
The same rules apply to the other European countries that share a common border with Switzerland (Germany, Austria and Italy).

And what about the complementary insurance?

If the person insured is covered by a complementary insurance with the LAA (commonly known as the LAAC), can they be reimbursed for the 30% remaining at their expense? This is a question we have asked of the various insurance companies. The least we can say is that their answers are highly divergent. Between those who refuse any possibility of coverage, those who might reimburse depending on certain clauses of the contract and with certain conditions, or even those who will reimburse the remainder under the auspices of the LAA, only one thing is certain: policy holders must definitely contact their insurance companies to determine their policy on this matter. Please feel free to contact us to accompany you and to decipher the terms of your contract.
 
Also, if you do not have LAAC coverage or if the insurer does not cover the remaining costs, do contact the Swiss Risk & Care teams who will be able to provide you with a solution.

What you need to know to be reimbursed by your insurer

For care in France, if the Swiss insurance company agrees to reimburse the remainder that you would have to pay yourself, you must, in general and at a minimum, submit the following documents to them:
  • The final statement from the Social Security showing the amount remaining at your expense
  • Copies of the invoices (if they have not already been sent by the Social Security and/or the care provider)
  • The accident declaration form: it is not you, but your employer, who must transmit this to the insurance once it has been established by both of you
If the insurer wishes to obtain the medical report, the request must be made directly to the care provider without going through the person insured.
 
We hope that, within a few weeks, the insurance companies will have defined and harmonised their positions on this subject. In any event, this is the purpose of our approach to them as insurance broker. However there remains the basic question that this new system has brought to light: what about the principle of equal treatment for Swiss and cross-border workers, as defined in our Constitution?
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