Accident Insurance Claims: Employer, Employee & Mutual Rights
No. 1: A worker suffers a heart attack while performing administrative work and subsequently dies.
- Is the insurance company required to pay supplemental accident insurance?
Mutual Accident and Occupational Diseases associations are governed by the LGSS for myocardial events. While insurance policies fall under the scope of the PSC and must be construed accordingly, if the policy clearly defines “accident” for death benefit purposes, and a stroke can be considered a “bodily injury due to the direct action of a sudden, violent, external event, outside the will of the insured,” the company must pay additional insurance. In this case, if the heart attack can be considered a consequence of a “sudden, violent, external event,” then the Mutual is obligated to pay.
- Is there subsidiary liability for the Mutual?
No, in any case. Mutual Accident and Occupational Diseases associations have no responsibility for what the employer has negotiated with an insurer on PSC.
- Which jurisdiction handles the claim?
Given the professional relationship between the policyholder and insured, the social jurisdiction applies.
No. 2: A worker suffers a work accident in June 2001 and is declared permanently and totally disabled on August 2, receiving a supplementary benefit of €9,000.
- How much is owed to the worker as a supplementary benefit, and by whom?
The worker is owed €9,000, the amount stipulated by the insurance policy at the time of accrual (June 2001, when the work accident occurred).
- Is the company excluded from liability?
This depends on whether the exclusion was made with the employer’s consent. Unilateral changes to the contract are not permitted. Recent case law suggests that if the employer consents to a clause limiting rights contained in an insurance contract originating from a collective agreement without the express consent of the workers, it may not be correct due to the insurer’s professional obligation to meet this requirement.
Key Highlights:
- Understand the concept of accrual and when it takes place in cases of accidents or illnesses leading to death or disability.
- Insurance contracts cannot be unilaterally changed by either party, and provisions limiting rights require the insured’s consent to be valid.
No. 3: A company establishes a retirement pension supplement for its employees in 1986 through an agreement with workers.
Will a collective claim succeed? This is an agreement freely made between workers and employers. If the agreement lacks provisions for annual increases and there is no insurance policy to reference, the agreement will be interpreted under labor law and SS rules, potentially qualifying it for “more favorable conditions.” Therefore, a conflict may arise.
Key Case Points:
- There is no insurance policy to interpret on its own terms, only an agreement that, by default, should be interpreted according to labor law (due to its employment background) and SS rules.
- Understand the concept of “more favorable terms.” The principle of benefit adjustment is not applicable because it is a PSC.