Basic principles of industrial accidents. Principles and functions of social insurance against industrial accidents and occupational diseases
Thus, the Institute of OSS against industrial accidents and occupational diseases provides except compensation payments a whole range of insurance services related to accident prevention mechanisms, training programs for training personnel for safe work, as well as the provision of medical and rehabilitation assistance to those injured at work.
The subjects of relations under OSS against industrial accidents and occupational diseases are the insured persons (employees), the policyholder and the insurer.
The most important functions of insurance against industrial accidents and occupational diseases are:
- - the function of compensation for material damage to the income of workers from damage to their health and loss of their ability to work;
- - financial activities of the insurer for the accumulation and management of financial resources;
- - organization of comprehensive social protection victims through compensation payments, medical and rehabilitation assistance;
- - assessment and analysis of the causes of occupational risk due to industrial accidents and occupational diseases;
- - taking proactive measures to reduce the likelihood and severity of the consequences of professional risks.
The insured person, in the event of damage to his health and ability to work, is compensated for the loss wages and the costs of medical care are reimbursed, and medical, professional and social rehabilitation programs are organized aimed at maximizing the possible restoration of working capacity and providing the opportunity for professional retraining and employment. Thus, the insurer, represented by its specialists, organizes comprehensive social protection of injured persons through compensation payments, medical and rehabilitation assistance.
Another function of the insurer is to identify and analyze typical mass occupational risks of industrial injuries and occupational diseases. For this purpose, the insurer’s specialists include a staff of highly professional technical inspectors and medical workers, which conduct systematic checks for the presence of risk factors in workplaces and industries. These workers have the right to issue instructions to employers in order to eliminate violations of safety rules during the operation of machinery and equipment and the organization of work.
Assessment, identification and prevention of risk situations can best be organized with the specialization of technical inspectors and medical workers in the same types of industries and production, the use of modern diagnostic instruments, methods and procedures, the capabilities of research centers and laboratories to identify design flaws in equipment and risk factors , available in technological processes.
The insurer's control function includes in its arsenal of tools:
- - penalties for employers and employees for gross violations of safe operating rules;
- - punishment of guilty persons by completely or partially denying them insurance coverage.
An extreme measure against policyholders (employers) for violating the rules of safe activities at work is to impose increased insurance premiums on them, which financially burdens them and requires them to change their attitude towards safe activities.
The most serious instrument of influence on individual employers who commit rude and, often, deliberate actions that result in accidents at work is the refusal to reimburse them for the costs of accidents through insurance mechanisms. Imposing on them the costs of compensating workers for harm, if the cause of the accident was gross negligence on the part of the employer, emphasizes the uncompromising position towards malicious violators of safe work practices.
Another area of the insurer’s preventive activities in the field of assessing and minimizing professional risks is the formation of “anti-risk behavior” among enterprise personnel. To this end, insurer specialists carry out extensive educational work at enterprises to explain to employers and employees the physical, chemical, biological and psychological nature of occupational hazards. It is believed that employers and employees will correctly perceive the requirements of safe work and respond to potential dangers through not only administrative and repressive measures, but based on an understanding of the nature of the manifestation of risks, the formation of their motivational attitudes and an internal culture of safe behavior at work.
- Insured persons for this type social insurance are citizens of the Russian Federation, as well as Foreign citizens and stateless persons, unless otherwise provided by federal law or an international treaty of the Russian Federation.
Article 5. Basic principles of accident insurance
Basic principles of insurance from an accident are:
parity of the state, representatives of insured persons and employers in the management of accident insurance;
timely and full compensation for damage by the insurer;
compulsory accident insurance for persons who work under the terms of an employment agreement (contract) and other grounds provided for by labor legislation, as well as the voluntariness of such insurance for persons who provide themselves with work independently, and citizens who are business entities;
provision of state guarantees realization of their rights by insured citizens;
mandatory payment by the policyholder of insurance premiums;
formation and expenditure of insurance funds on a joint and several basis;
differentiation of the insurance tariff taking into account conditions and state of labor safety, industrial injuries and occupational morbidity at each enterprise;
economic interest of insurance entities in improving working conditions and safety;
target use of accident insurance.
Article 6. Subjects and objects of accident insurance
The subjects of accident insurance are insured citizens, and in some cases - members of their families and other persons, policyholders and the insurer.
The insured is an individual, in the interests of whom insurance is provided (hereinafter referred to as the employee).
Employers are the insurers, and in some cases - insured persons.
Insurer - Social Insurance Fund from industrial accidents and occupational diseases of Ukraine (hereinafter referred to as the Social Accident Insurance Fund).
Object of insurance against accident case is the life of the insured, his health and ability to work.
Article 7. Employer
In accordance with this Law, an employer is considered to be: a legal entity (enterprise, institution, organization) or an individual who, within the framework of labor relations, uses the labor of individuals.
Article 8. Persons subject to compulsory accident insurance
Compulsory insurance from accidents are subject to:
1) persons who work under the terms of an employment contract(contract) or on other grounds provided for by labor legislation;
2) pupils and students of educational institutions, clinical residents, graduate students, doctoral students involved in any work temporarily, before or after classes; during classes, when they acquire professional skills; during the period of practical training (internship), performing work at enterprises;
3) faces who are kept in correctional, medical-labor, educational- labor institutions and are involved in labor activities in production in these institutions or at other enterprises under special contracts.
Article 9. Insurance of the embryo and newborn
Causing harm to the fetus as a result of injury at work or an occupational disease of a woman during her pregnancy, due to which the child was born disabled, is equivalent to an accident that happened to the insured. Such a child, in accordance with a medical examination, is considered insured and until 18 years of age or until graduation, but no more than until he reaches 23 years of age, assistance from the Social Accident Insurance Fund is provided.
Article 10. Employee insurance procedure
Insurance against accidents at work does not require the consent or application of the employee. Insurance is carried out in an impersonal form. All persons listed in Article 8 of this Law are considered insured from the moment this Law comes into force, regardless of the actual fulfillment by policyholders of their obligations regarding the payment of insurance premiums.
All insured persons are members of the Social Accident Insurance Fund.
Article 11. Voluntary insurance from an accident
Voluntarily from an accident can insure:
1) persons who provide themselves with work independently- engaged in legal, notarial, creative and other activities related to receiving income directly from this activity, members of a farm, personal peasant farm, if they are not hired workers;
2) citizens are subjects of entrepreneurial activity.
3) clergy, clergy
Article 12. Certificate of accident insurance
Persons subject to accident insurance are issued a certificate of compulsory state social insurance, which is the same for all types of insurance.
Article 13. Insurance risk and insured event
Insurance risk - circumstances as a result of which an insured event may occur.
An insured event is an industrial accident or occupational disease that caused the insured person to have a professionally determined physical or mental injury under the circumstances specified in Article 14 of this Law, upon the occurrence of which the insured person’s right to receive material security and/or social services arises.
An occupational disease is also an insured event if it is established or detected during a period when the victim was not in an employment relationship with the enterprise where he became ill.
Violation of labor protection rules by the insured, which resulted in an accident or occupational disease, does not relieve the insurer from fulfilling obligations to the victim.
The basis for payment to the victim of expenses for medical care, medical, professional and social rehabilitation, as well as insurance payments, is an act of investigation of an accident or an act of investigation of an occupational disease (poisoning) in accordance with established forms.
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Introduction
insurance accident damage payment
Insurance as a field financial activities arose from the division of social labor and developed as man realized the value of his life, health and property.
In the context of the transition to a market economy, insurance is one of the fastest growing industries economic activity. Market economy, and above all the non-state sector of the national economy, places a demand for various types of insurance, since private property, unlike state property, needs comprehensive insurance protection. She does not have financial guarantees from the state behind her and wants to protect herself from the consequences of possible risks.
Insurance is one of the oldest and most stable forms of ensuring economic life, rooted in distant history. Insurance is carried out on the basis of property or personal insurance, concluded by a citizen or legal entity (policyholder) with an insurance organization (insurer). At its core, insurance is the creation of trust funds Money, intended to protect the property interests of the population in private and economic life from natural disasters and other unforeseen emergency events of their nature, accompanied by damage.
In society, insurance plays the role of a mechanism that redistributes financial resources(insurance fund) from all members of society to those who need financial assistance as a result of insured events that happened to them. Unlike social insurance, where most or all citizens are insured, in commercial insurance redistribution occurs only between members of a particular insurance fund who paid insurance premiums to it.
Accident insurance is the most traditional type of personal insurance for insurance practices. The main purpose of accident insurance is to compensate for damage caused to the health and life of the insured as a result of an accident.
Accident insurance is a traditional type of life insurance, the content of which is Lately changed due to the inclusion of additional insurance coverage in the form of insurance against deadly diseases, thus the full modern name of this type is insurance against accidents and illnesses. The main purpose of accident insurance is to compensate for damage caused to the health and life of the insured as a result of an accident or illness.
1. Item withinsurance and insurance coverage
1.1 History of accident insurance
Accident insurance has undergone significant changes over the years of market reforms. They are associated with the introduction of compulsory types of accident insurance for certain categories and groups of the population, the development of collective forms of insurance for employees of enterprises and organizations, the emergence and rapid spread of such a new type of insurance for domestic practice as insurance for citizens traveling abroad.
In the classification of types of insurance activities given by Rosstrakhnadzor in the Conditions for licensing insurance activities on the territory of the Russian Federation, traditional accident insurance is replaced by insurance against accidents and illnesses and is defined as “a set of types of personal insurance that provide for the insurer’s obligations for insurance payments in fixed amount, either in the amount of partial or full compensation additional expenses the insured caused by the occurrence insured event" As practice shows, in most cases, insurers limit their liability only to accidents, leaving the risk of illness within their competence health insurance and life insurance.
The main purpose of accident insurance is to compensate for damage caused to the health and life of the insured as a result of an accident.
Accident insurance dates back to the 19th century. Its appearance is largely connected with the emergence and development of railway transport. However, the idea of accident insurance was known much earlier. The Visby maritime law of 1541 required the owner of a ship to insure the life of his captain against accidents. In Holland, already in 1665, there was a reward sheet for the loss of various members of the body for mercenary troops. In the 18th century, mutual aid unions were created in Germany in case of fractures. In the 19th century, this type of insurance began to develop in England, where railway communication appeared earlier than other countries.
In the development of accident insurance in Russia big role labor legislation played a role. Under pressure from the labor movement and the adoption of European states by the law of June 2, 1903. Rules were adopted on remuneration for victims of accidents of workers and employees, as well as members of their families, in enterprises of the factory, mining and mining industries. This document introduced the employer’s obligation to compensate for damage caused to an employee as a result of an industrial accident, in the form of temporary disability benefits (50% of earnings), compensation for medical expenses, a disability pension and a survivor’s pension, as well as payment of a fixed benefit for burial.
In 1912, as part of a whole package of documents introducing compulsory insurance for hired workers, a more advanced document was adopted - the Law and Appendix on accident insurance for workers. Compulsory accident insurance applied to all workers employed in the factory and mining industries, in shipping and railway transport private use and some others.
Except compulsory insurance Voluntary forms of accident insurance also developed widely in pre-revolutionary Russia. It was carried out both by large joint-stock companies and by mutual insurance companies.
In Soviet times, compulsory insurance against industrial accidents was introduced into the social insurance system, and its implementation was entrusted to a specially created State Fund social insurance, which until the early 1990s. governed by trade unions.
Voluntary accident insurance was provided by Gosstrakh. This type of insurance was the most popular in the field of personal insurance.
During the period of market reforms of the 1990s. The scope of application of accident insurance has expanded significantly: it provides the insured and their family members with comprehensive protection against economic consequences disability or death resulting from unforeseen and random events.
The practice of accident insurance shows that it can be carried out in various forms, while maintaining a single socio-economic content. Currently, in the Russian Federation, accident insurance can be mandatory, carried out by force of law, or voluntary, carried out on a commercial basis.
1.2 Accident concept
Insurance is carried out on the basis of a personal insurance contract concluded by a citizen or legal entity
An accident is understood as a sudden, external, unforeseen impact on the human body, the result of which is harm to the health of the insured.
“Suddenness” means that the accident must be a relatively short-term event (this does not apply to its consequences, i.e. harm to the health of the victim).
If a person has been exposed to harmful environmental influences for a long time, then these effects cannot be classified as an accident.
Likewise, damage to health due to excessive stress over a long period of time, such as when playing sports, cannot be considered an accident.
While sunbathing in the sun, the vacationer fell asleep and received severe burns.
There is no sign of suddenness, since the effect of the sun on the human body was gradual.
The skier hit a tree, fell and was injured.
Hitting a tree should be classified as a sudden action.
The concept of surprise also includes elements of the unexpected, unforeseen and inevitable. This means that in certain cases an event lasting a relatively long time can be considered sudden.
For example, the death of an insured that occurred as a result of prolonged inhalation of toxic gases from a faulty stove should be classified as an accident if he was unable to notice the leak of gas, which has neither color nor odor, or did not have time to do anything because he lost consciousness.
External nature of the impact.
Effects on humans classified as an accident can be mechanical, chemical, thermal and electrical. Organic and functional changes that occur in the human body throughout his life are internal influences, such as stroke or heart attack, and do not belong to this category of events. People's own actions can also be considered as external influences.
Impact on the human body
Under the influence classified as an accident, insurance understands both a natural phenomenon, such as fire, ice, and the actions of people themselves that harm their health.
Continuous nature
In insurance, an impact on the human body is considered an accident only if, as a result of its occurrence, the health of the insured unforeseen was harmed. Suicide, as well as self-inflicted bodily harm by the insured, are not included in the insurance coverage.
It should be emphasized that the sign of unforeseenness refers not to the event, but to the harm caused to the health of the insured person as a result of its occurrence. Health damage caused as a result of self-defense or in an attempt to save a human life should be considered unintentional. Events that occurred as a result of the gross negligence of the insured person as a result of its occurrence.
Health damage caused as a result of self-defense or in an attempt to save a human life should be considered unintentional.
Events that occurred as a result of the gross negligence of the insured person are also considered an insured event unless the insurer can prove that the injury was caused intentionally.
Damage to the health of the insured
An external impact on the human body is an accident if the immediate result of this event is harm to the health of the insured in the sense of a violation of the anatomical and physiological integrity of the body. Therefore, property damage resulting from external influences on the insured, for example damage to prosthetic limbs, dentures or glasses, is not subject to compensation under this type of insurance. For payment insurance compensation it does not matter what kind of harm was caused to the health of the insured. The term “harm to health” is not limited in meaning to direct bodily injury. It is enough if, as a result of external influence, the insured person suffered mental trauma, which can be expressed in nervous excitement, shock, anger, etc.
It is important to emphasize that in order to recognize an event as an insured event, there must be a cause-and-effect relationship between the accident, harm to the health of the insured and the damage subject to insurance compensation. The burden of proof is placed by law on the policyholder.
An accident is also considered to be events in which, due to physical overexertion, the insured person experiences a dislocation of the spine or joints of the limbs, or a sprain or rupture of muscles, tendons, ligaments or joint capsules.
Thus, an accident is recognized not only as damage caused to the health of the insured as a result of a sudden external influence, but also due to excessive physical exertion. This refers to the conscious actions of the insured himself, leading to excessive strain, which, in turn, harms his health in the form of dislocations, sprains and tears.
Damage to the intervertebral discs and meniscus, related to age-related changes in the body, but manifested after severe physical activity, are excluded from insurance coverage. This is explained by the fact that, from an anatomical point of view, the intervertebral discs and meniscus are cartilage, and not tendons, ligaments, muscles or a joint capsule. Therefore, this coverage expansion only applies to typical sports-related injuries.
Exclusion from insurance coverage
There are two groups of exceptions: certain events and certain types of damage.
Exceptions to insurance coverage are the following events, which, by all indications, are an accident, but the consequences of which are not covered by insurance coverage.
Accidents that occur as a result of mental disorders or disturbances of consciousness, including those caused by alcohol or drug intoxication of the insured person, as well as stroke, epileptic seizure or convulsions affecting the entire body. Insurance guarantees remain, however, if these disorders or seizures were caused by an event included in the insurance coverage under the contract.
Accidents in which the insured person was involved as a result of committing or attempting to commit illegal actions.
Military actions, civil wars and other internal unrest, if the insured took part in or a civil war caught the insured person unexpectedly abroad, then he is covered by insurance coverage for this type of insurance for seven days.
Accidents that occurred to the insured while operating aircraft, including sports aircraft, or while in them as a crew member (if this is the professional activity of the insured). These risks can be included in the insurance coverage when concluding special insurance contracts through the German Aeronautical Society. In addition, some insurers currently already offer appropriate additional insurance coverage as part of voluntary accident insurance.
Racing competitions on motor vehicles. Insurance coverage does not apply not only to the driver, but also to other people inside the vehicle participating in racing.
Accidents caused by exposure to atomic energy. The exception is not only damage caused by nuclear radiation, but also accidents resulting from explosions, sudden changes in pressure, due to panic, etc.
Insurance coverage excludes damage caused to the health of the insured as a result of the following events:
Damage caused by all types of ionizing rays is excluded from insurance coverage. If the cause of the disease is radiation therapy, then insurance coverage remains provided that this therapy was prescribed to treat the consequences of an accident insured under the relevant contract. Persons who, due to the nature of their activities, are exposed to increased radiation exposure, can insure the risk of occupational disease by including appropriate clauses in the accident insurance contract or by concluding special insurance contracts.
Carrying out therapeutic measures and surgical intervention, if they were not caused by the need to treat the consequences of an accident.
For persons in certain professions associated with an increased risk of infectious diseases, for example doctors, paramedical personnel, it is possible to include these risks in insurance coverage in cases where pathogens entered the insured body through damage to the skin or by injection.
Infectious diseases.
Insurance coverage remains, however, if the causative agent of an infectious disease enters the body of the insured person as a result of injuries or injuries received as a result of an accident included in the insurance coverage under this contract. Minor damage to the skin and mucous membrane, through which pathogens could enter the insured person’s body immediately or after a certain time, are not considered injuries as a result of an accident.
Infectious diseases have the nature of a disease. That is why they are excluded from insurance coverage under accident insurance contracts. The insurer's liability remains only in those cases where at the beginning of the chain of cause-and-effect relationships there is an insured accident and the causative agent of the disease enters the body of the insured person as a result of damage caused by this accident. AIDS and its consequences are also excluded from insurance coverage if the infection occurred through minor lesions of the skin or mucous membrane.
Poisoning due to ingestion of solid or liquid substances through the throat.
It should be emphasized that it is the entry of toxic substances into the body through the pharynx that is the main condition for exclusion from insurance coverage. If the insured inhales or injects a poisonous substance, coverage will continue.
Receiving a toxic substance through the throat also means that the insured himself takes actions through which it enters the body. It does not matter whether he acted voluntarily or under duress, knowingly or in ignorance. If a toxic substance enters the body of the insured through the actions of third parties, then the insurer's liability remains.
Exclusions from insurance coverage include hernias of the white line of the abdomen and inguinal hernias, except for cases when they arose as a result of violent external influence on the insured.
Coverage does not apply to intervertebral disc injuries or bleeding internal organs, unless they were caused by an insured accident.
Nervous disorders, which are the mental reaction of the insured to certain events, are also excluded from insurance coverage.
Some companies insure accidents that occur as a result of impaired consciousness of the insured due to alcohol intoxication. When driving a vehicle, however, the maximum blood alcohol limit should not exceed 1.3%
A number of insurers also offer insurance for the so-called passive risk of war.
Types of insurance guarantees
Voluntary accident insurance in case of death offers a wide range of insurance guarantees that are included in contracts by agreement of the parties. When concluding an insurance contract, the policyholder has the right to freely choose the type and amount of insurance coverage.
The most important guarantee provided by the accident insurer is the guarantee of insurance payments in case of disability, which is necessarily included in the contract. Other types of guarantees are agreed upon additionally at the discretion of the parties. Disability insurance benefits include:
Insurance benefits in case of death
Daily cash allowance
Daily cash benefit during hospital stay
Cash benefits during the recovery period, including payment for sanatorium treatment, space operations, etc.
1.3 Object and subjects of accident insurance
Accident insurance guarantees protection in the form of compensation in the event of an accident.
The object of accident insurance under Russian law is the property interests of the insured associated with loss of ability to work or death due to an accident.
The main subjects of insurance relations are policyholders and insurers. Under a personal insurance contract, one party (insurer) undertakes, for a fee stipulated by the contract (insurance premium) paid by the other party (the policyholder), to pay a lump sum or periodically pay the amount stipulated by the contract (insurance amount) in the event of harm to the life or health of the policyholder himself or another named in the contract. contract of a citizen (insured person).
Insurers are legal entities and capable individuals who have entered into insurance contracts with insurers or are policyholders by force of law
Insurers are legal entities created in accordance with the legislation of the Russian Federation to provide insurance, reinsurance, mutual insurance and received licenses in the manner prescribed by this Law.
Insurers assess insurance risk and receive insurance premiums ( insurance premiums), form insurance reserves, invest assets, determine the amount of losses or damage, produce insurance payments, carry out other actions related to the fulfillment of obligations under the insurance contract.
1.4 Insurance cover
Accident insurance offers four basic guarantees. However, in practice, insurers may use different combinations of these standard covers or exclude some of them from private insurance conditions.
Accident insurance guarantee system:
Basic guarantees:
Sum insured in case of death;
Sum insured in case of disability;
Daily temporary disability benefit;
Payment of medical expenses for treatment;
Additional guarantees:
Survivor's pension;
Disability pension;
Care allowance;
Payment of expenses for prosthetics and cosmetic surgery;
Payment of expenses for sanatorium-resort treatment necessary for rehabilitation.
The guarantee in case of death as a result of an accident involves payment to the beneficiary specified in the insurance contract, or to the heirs of the insured as determined in the private insurance conditions sum of money. At the request of the policyholder, the capital can be paid in the form of annuity (pension).
There are two approaches to determining disability rates . In the first case, insurance companies, based on their own statistical observations, develop tables that evaluate loss of disability based on the complete loss or loss of functionality of various organs, or use government tables used in determining compensation for damages from industrial accidents.
Table 1. Coefficients for calculating disability for complete loss or functional unsuitability of body parts and sensory organs
Complete loss or permanent functional incapacitation of a body part or sensory organs |
Disability rate, % |
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One eye |
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Hearing in one ear |
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Smell |
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Taste sensations |
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One arm at the shoulder joint |
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One arm above the elbow joint |
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One hand to the elbow |
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One hand |
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One thumb |
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One index finger of the hand |
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One finger of the hand: middle, ring or little finger |
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One leg above mid-thigh |
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One leg to mid-thigh |
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One leg to the knee |
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One leg to mid-calf |
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One foot at the ankle joint |
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One big toe |
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One any other toe |
If, within one year from the date of the accident, an irreversible deterioration in the physical or mental condition of the insured (disability) occurs as a result, then he is paid insurance compensation in the form of a certain amount of money, the amount of which depends on the degree of disability.
Such a broad definition of the concept of disability was not chosen by chance. On the one hand, it includes the deterioration of all functions of the human body. On the other hand, such a definition, such a definition can be used in relation to insured persons of all age groups, regardless of the nature of their activities.
Disability must be determined by a doctor within three months after one year after the accident, which the policyholder must notify the insurer in accordance with the established procedure.
The temporary disability guarantee provides the insured with compensation in the form of a daily benefit during treatment and rehabilitation.
The provision of this guarantee has significant features. Firstly, the amount of the benefit is set in proportion to the insurance amount specified in the contract for the risk of temporary disability. The maximum limit for the benefit amount is taken to be the average daily labor income of the insured person. Secondly, a temporary disability guarantee usually contains a deductible, expressed in the number of first days of disability during which benefits are not paid. The most common deductible is seven days. Thirdly, the guarantee in case of temporary disability has a limitation on the duration of the benefit payment period. This period is stipulated in the private insurance conditions and is traditionally 365 days.
The guarantee of payment for medical expenses necessary to treat the consequences of an accident includes reimbursement of costs for hospitalization, outpatient treatment, medications, and care.
As an option, payment of expenses for prosthetics, cosmetic surgery and spa treatment may be offered. The amount of guarantees is determined as a percentage of expenses incurred. For basic guarantees, payment can be set at 100% of medical expenses, for additional guarantees no more than 20-50%. Typically, the amount of this guarantee depends on the extent to which treatment costs are covered by social insurance or social security.
Speaking in general about insurance coverage for accident insurance, it is necessary to highlight two different approaches to determining the specific volumes of insurance payments. The insurance company sets all guarantees as a percentage of a single death benefit or uses different insurance amounts to determine each guarantee. Domestic insurers prefer to calculate all guarantees based on one sum insured in case of death, using different percentage standards. However, in any case total amount payments of insurance compensation for one or more insurance events that occurred during the validity period of the insurance contract cannot exceed the insured amount specified in the contract, or the insured amounts for each guarantee if several insurance amounts are specified in the contract.
The standard rules of accident insurance, developed by the All-Russian Union of Insurers, recommend determining the amount of insurance payment as a percentage of the sum insured for a given type of insured event in accordance with the table of insurance payments when the insured person pays for the total working capacity as a result of an accident on the basis of a certificate from a medical institution , as a rule, without examination of the insured person (Table 3). If the insured person has suffered damage to soft tissues, organs of vision, hearing or the genitourinary system, he may be referred by the insurer for examination by a specialist doctor to determine the consequences of such damage. According to the same Rules, in connection with the onset of temporary disability, it is paid in the amount of 0.2% of the insured amount for this type of insured event for each day of incapacity, starting from the 6th calendar day of incapacity, but not more than 90 days per year.
Table 2. Excerpts from the table of payments in case of loss of general working capacity by the insured person as a result of an accident, % of the insured amount
Nature of damage or its consequences |
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Concussion requiring treatment for 10 days or more |
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Brain contusion |
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Paralysis of accommodation of one eye |
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Damage to one eye resulting in complete loss of vision in one eye |
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Damage to one or both eyes resulting in complete loss of vision |
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Complete deafness |
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Rupture of the eardrum resulting from trauma, without hearing loss |
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Lung damage resulting in: |
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pulmonary failure |
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removal of part, lobe of the lung |
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lung removal |
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Sternum fracture |
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Fractured ribs: |
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three ribs |
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each next rib |
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Jaw fractures: |
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upper jaw, zygomatic bones |
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lower jaw, dislocation of the lower jaw |
2. Types of accident insurance
2.1 Compulsory accident insurance in the Russian Federation
Compulsory accident insurance is one of the elements of the social insurance system and covers the risks of industrial injuries and occupational diseases. Its scope is limited to the consequences of accidents occurring at the workplace or during working hours (including while traveling to and from work). An essential feature of this type of insurance is that insurance premiums are fully paid by the employer. In Russia, compulsory accident insurance is regulated by the Law “On compulsory social insurance against industrial accidents and occupational diseases” dated July 24, 1998 No. 125-FZ (as amended on July 17, 1999) and its by-laws.
Another area of organizing compulsory accident insurance that complements or compensates for social insurance is compulsory state insurance life and health of those categories of civil servants whose professional activities are associated with an increased risk of accidents during the performance of their official duties. These include: judges, prosecutors, employees of the Ministry of Taxes and Duties, military personnel. State personal insurance covers risks identical to compulsory accident insurance: death and disability of the insured as a result of injury, mutilation, or bodily harm occurring during the performance of official duties. Compulsory insurance for civil servants is regulated federal legislation. The third area of compulsory accident insurance is compulsory personal insurance of passengers transported by air, rail, water and road transport on intercity and tourist routes.
Insurance against industrial accidents and occupational diseases
Mandatory accident insurance is one of the elements of social insurance and covers the risks of industrial injuries and occupational diseases. An essential feature of this type of compulsory accident insurance is that insurance premiums are fully paid by the employer. All employees, students, children attending preschool institutions, farmers and people working on farms are usually subject to compulsory insurance against accidents at work.
Mandatory insurance against industrial accidents and occupational diseases provides for social protection of workers through:
Compensation for harm caused to the life and health of workers during the performance of their duties employment contract or in other cases established by law;
Increasing the interest of enterprises and organizations in reducing the level of professional risk;
Financing preventive measures to reduce industrial injuries and occupational diseases.
Funds received for accident insurance can be used by the Social Insurance Fund for the needs of state social insurance as a whole, which is confirmed by federal laws on the fund’s budget. Insurance premiums for compulsory social insurance against industrial accidents and occupational diseases are paid by insurers directly to the Social Insurance Fund. All employers are insurers:
Legal entities of any organizational and legal form in relation to workers hired under employment agreements (contracts);
Individuals who hire other individuals under an employment agreement (contract).
Policyholders are required to register with the executive bodies of the Social Insurance Fund at their location. Insurance premium rates are approved annually by federal law for the next year. Insurance rates are established by the FSS on the basis of the Rules for classifying economic sectors as occupational risk. The amounts of insurance premiums are transferred by the policyholders monthly within the period established for receiving funds from banks to pay wages for the current month. Insurers who make established insurance payments to the insured who are in an employment relationship with them, insurance premiums are transferred minus the payments made.
The object of compulsory insurance against industrial accidents and occupational diseases is the property interests of individuals associated with their loss of health, professional disability or their death as a result of an industrial accident or occupational disease. The insured under this type of insurance are:
All individuals performing work on the basis of an employment contract concluded with the employer;
Individuals who have already suffered damage to their health as a result of an accident at work or an occupational disease, confirmed in the prescribed manner, by the time of implementation federal law on compulsory social insurance against accidents;
Individuals sentenced to imprisonment and recruited to work by the insurer.
An insured event is a duly confirmed fact of health damage or death as a result of an industrial accident or occupational disease. An industrial accident is an event due to which the insured suffered damage to health, leading to temporary or permanent loss of professional disability or death that occurred during the performance of duties under an employment contract both on the territory of the insurer and outside it, while traveling to place of work or compensation from the place of work on transport provided by the insured (or on personal transport used for official purposes under a contract or order of the employer). Accidents that occurred while traveling to the location business trips and vice versa, when working on a rotational basis during rest periods between shifts, when involving an employee in the liquidation of the consequences of emergency situations, when carrying out actions that are not part of the employee’s job duties, but performed in the interests of the employer (to prevent accidents, damage), also are considered as production.
The investigation and recording of industrial accidents is carried out in accordance with the regulations approved by the Decree of the Government of the Russian Federation of March 11, 1999. The employer is obliged to ensure timely investigation and registration of an accident at work. The costs of investigating the accident are borne by the employer. The loss of professional disability of the insured is established by institutions (bureaus) of medical and social examination on the basis of an application from the employer, insurer, or an independent application from the victim when submitting a report on an industrial accident.
The day of assignment of insurance payments is considered to be the day the fact of loss of professional disability by the insured person is established. In the event of an occupational disease, the date of harm is considered to be either the date of detection of the occupational disease, or the date of drawing up the act of investigating the occupational disease, if it is not possible to determine the moment of the disease. When investigating an insured event, the commission may establish the fault of the insured in the occurrence of the insured event - gross negligence that contributed to the occurrence or increase of the damage caused.
If, as a result of an insured event, the death of the insured occurs, then the following persons receive the right to receive certain insurance payments: 1) Disabled persons who were dependent on the deceased or who, on the day of his death, had the right to receive maintenance from him by the day of his death, the right to receive from him content, under the following conditions:
Children until they reach the age of 18, and students over 18 years old - until they graduate from full-time educational institutions, but not more than 23 years old;
Women who have reached the age of 55 years, and men who have reached the age of 60 years - for life;
Disabled people - for the period of disability; 2) a child of the deceased who was born after his death; 3) one of the parents, spouse or other family member, regardless of ability to work, who does not work and is engaged in caring for the deceased’s dependent children, grandchildren, brothers and sisters who, according to medical and social conclusions, have not reached permanent care; 4) persons who were dependent on the deceased and who became disabled within 5 years from the date of his death.
In the event of damage to the life, health and professional ability of workers, they themselves or their loved ones are guaranteed:
Temporary disability benefit;
Insurance payments - one-time, - monthly;
Payment of additional expenses for:
Additional medical care
Outside care for victims, - sanatorium-resort treatment,
Prosthetics and provision of necessary devices for work and at home,
Providing special vehicles and their contents,
Vocational training and retraining.
State life and health insurance for certain categories of civil servants
Another direction of organizing compulsory accident insurance, complementing or compensating for social insurance, is compulsory state life and health insurance for those categories of civil servants whose professional activities are associated with an increased risk of an accident during the performance of their official duties.
Military personnel, employees of the Ministry of Internal Affairs, tax inspectorates, the state fire service, prosecutors, investigators, judges and people's assessors, rescuers, deputies of the Legislative Assembly, workers at nuclear facilities, astronauts, healthcare workers providing diagnosis and treatment of HIV infection, donors and some others.
Initially, Rosgosstrakh was engaged in state personal insurance. However, since 1993 There has been a clear trend of policyholders moving to other commercial insurance companies, mainly captive-type companies, the founders of which are the policyholders themselves; the relevant ministries and departments are required to insure their employees. To carry out compulsory state personal insurance, an insurance company must have a license to provide the appropriate type of insurance.
Recently, the issue of creating a state insurance company in the form of a state unitary enterprise in order to provide compulsory personal insurance has been discussed. This is due to the fact that compulsory state life and health insurance for civil servants is carried out at the expense of state budget and a significant portion of these funds go to commercial insurance companies.
State personal insurance covers risks identical to compulsory social insurance against accidents: mutilation, bodily harm occurring in the performance of official duties. Insurance compensation is determined based on official salary or minimum size wages.
Passenger personal insurance
The third area of compulsory accident insurance is compulsory personal insurance of passengers transported by air, rail, water and road transport on intercity and tourist routes. The insurance covers the risk of death or personal injury resulting from a travel-related accident.
Maximum sum insured, subject to payment in the event of the death of a passenger, is established by law in the amount of 120 minimum wages on the date of purchase of the travel document. In the event of injury or disfigurement, the amount of insurance compensation is calculated in proportion to the severity of the injuries sustained as a result of the accident.
The policyholders are the passengers themselves, who pay an insurance premium for compulsory personal insurance upon purchase. travel ticket. However, the interests of the policyholders when registering this insurance operation were represented by the transport organization-carrier, which chooses insurance company and concludes an agreement with her on the implementation of this type of insurance. The only requirement for an insurance company is to have an appropriate license to provide compulsory passenger insurance. Passengers without the right to free travel are considered insured without paying an insurance premium.
Tariffs for compulsory personal insurance of passengers are approved by Rosstrakhnadzor and coordinated with the ministries of transport and communications of the Russian Federation. The main part of the tariff consists of contributions to the preventive measures fund, the funds of which are sent to the institutions of these ministries for the purpose of improving transportation safety (Table 1)
Table 3. Tariff structure for compulsory personal insurance of passengers of railway and intercity road transport
Mandatory personal insurance for passengers in the form in which it is carried out raises a lot of criticism. Firstly, the deduction of more than 90% of the insurance tariff to finance the carrier's expenses makes compulsory passenger insurance more like an additional taxation of the population. Secondly, transferring the carrier’s responsibility for the life and health of the passenger onto the passenger himself is a measure unworthy of a civilized society. In many countries, this issue has been resolved by introducing the institution of compulsory financial liability of the carrier for the life and health of passengers, and in some cases, compulsory liability insurance of the carrier. The current practice of compulsory passenger insurance in Russia contradicts its civil legislation. In paragraph 2 of Art. 935 ch. 48 of the Civil Code of the Russian Federation states that the obligation to insure one’s life or health cannot be assigned to a citizen by law. In the interests of protecting consumer rights, it would be legitimate to establish the carrier’s liability for the life and health of passengers.
2.2 Voluntary accident insurance
Voluntary insurance is carried out on the basis of an insurance contract and insurance rules defining General terms and the procedure for its implementation.
Insurance rules are adopted and approved by the insurer or association of insurers independently in accordance with Civil Code of the Russian Federation and this Law and contain provisions on subjects of insurance, on objects of insurance, on insured events, on insurance risks, on the procedure for determining the insured amount, insurance tariff, insurance premium (insurance contributions), on the procedure for concluding, executing and terminating insurance contracts, on the rights and obligations of the parties, on determining the amount of loss or damage, on the procedure for determining insurance payment, on cases of refusal of insurance payment and other provisions.
Voluntary accident insurance has several organizational forms. First of all, there is a distinction between individual and collective accident insurance.
An individual insurance contract is concluded by an individual, and the contract mainly applies to the policyholder and his family members.
Under contract collective insurance the policyholder is entity, and the insured are individuals in whose life and health the policyholder has a material interest.
Collective accident insurance
Collective insurance contracts are concluded either by employers in favor of their employees, or by various associations and societies in favor of their members. Contributions for collective insurance are significantly lower than for individual ones, since additional risk equalization occurs within a certain group.
IN Russian Federation collective accident insurance has its own specifics due to the peculiarities of the pre-existing tax legislation, which made it possible to use this form to avoid profit tax, income tax and contributions to off-budget funds social significance. Enterprises used accident insurance to provide employees with additional cash payments, bypassing those established by law mandatory deductions and payroll taxes. This situation was possible due to the legal existence of insurance with the return of insurance premiums and preferential taxation of insurance premiums and insurance payments.
Currently, accident insurance has a less favorable tax regime for insurance premiums and payments. Thanks to the tightening of the rules for taxation of insurance premiums, this type of insurance has become less attractive for use in order to provide “hidden” wages.
Individual accident insurance
Individual voluntary accident insurance exists in the following forms:
Comprehensive accident insurance providing insurance guarantee for any period of both private and professional life of a person during the validity of the contract;
Partial insurance, which provides a guarantee only for a certain period of human life; the most common is accident insurance for the duration of travel, travel, including abroad;
Additional insurance, i.e. the use of accident insurance as a component of various combined or package policies; guarantee of payment of double the insured amount in the event of death as a result of an accident in life insurance; guarantee for accidents in the package policy of the head of the family, etc. Accident insurance is the most common addition to many insurance policies and the most profitable risk for insurers within the framework of personal insurance.
3. Insurance rates
Insurance rates for accident insurance are determined according to the methods used in constructing tariffs for risky species insurance. Accident insurance refers to damage insurance, therefore the pricing is based on the principle of distributing the insurance risk among all insured. The calculation of the net rate for accident insurance takes into account the average loss ratio of the insured amount for this type of insurance.
Accident insurance rates generally depend on the gender and age of the insured. Insurance rates increase with the increase in the amount of the insured amount and the danger of the activity carried out by the insured, primarily professional. Insurance rates increase with an increase in the size of the sum insured and the degree of riskiness of the professional and public duties of the insured. Insurers use their own scales for matching tariffs and insurance amounts, as well as grouping professions depending on the potential danger.
The standard rules for voluntary insurance of citizens against accidents contain the following recommendations for determining the sum insured and insurance premiums and the terms of their payment. The insured amount is determined by agreement between the policyholder and the insurer for each type of insured event separately and may be different or the same for the selected types of insured events. If the policyholder enters into an insurance contract for several persons, then the contract indicates the total insurance amount for all insured persons and for each type of insured event. If the individual insurance amounts are equal, the total insurance amount is determined by multiplying the insurance amount established for one insured person by the number of persons named in the contract. If individual insurance amounts are different, then the total insurance amount under the contract is determined by adding the insurance amounts for each insured person.
Basic insurance rates are developed by the insurer independently. IN special cases When determining the amount of the insurance premium, the insurer has the right to establish increasing and decreasing coefficients to the basic insurance rates, determined depending on the individual characteristics of the risk. The insurance premium under insurance contracts concluded for a period of no more than one year is paid at a time. When concluding a contract for a longer period, it is possible to pay the premium in installments, over two terms, and the first insurance premium must be at least 50% of the entire insurance premium. The second part of the insurance premium must be paid no later than half the term of the contract has passed. The insurance rate is set as an annual rate. When insuring for a period of less than a month insurance premium paid at the rate of 0.7% annual rate for each day of validity of the insurance contract.
The insurance premium can be paid in different ways:
By non-cash transfer to the insurer's bank account within five banking days from the date of signing the insurance contract, unless otherwise specified in the insurance contract;
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