How to get money from health insurance. Payments for an industrial injury to an employee by an employer. Collection and submission of documents to obtain insurance

Injuries sometimes occur at work, the state protects injured citizens, and compensation is provided for people who have received work-related injuries. The employer can also compensate the employee for part of wages or full monthly salary. ABOUT legal basis such relationships, read the article.

According to Article 5 Federal Law on social insurance against accidents at work, industrial damage covers accidents that happen to an employee at work. Russian legislation provides financial compensation for a work injury in the form of both a one-time and regulatory payment. To receive money, health damage must be documented in accordance with legal requirements. This means that the victim must contact doctors and take sick leave. An industrial injury and the costs associated with it must be compensated by the employer or the Social Insurance Fund.

Work injury payments and compensation 2018

If an employee receives a work-related injury, he or she has the right to compensation for sick leave and rehabilitation from the employer. If severe or moderate damage has been caused to health, affecting the employee’s ability to work, then the amount of compensation is determined by a medical and social examination. It is the employee’s responsibility to enable doctors to determine what harm was caused to the body at work.

The employer also has the right, after an accident at work, to pay the employee additional compensation, which is issued in a separate order or provided for in the agreement/contract.

Procedure for payment of insurance compensation and terms

If an employee was injured at work, the procedure is as follows: within ten days, in order to receive payment for an industrial injury at the enterprise, the employee must collect documents and go to the Federal Social Insurance Fund of Russia, attention: not to the employer. According to the law, a one-time insurance payment is transferred to the employee immediately.

Depending on the duration of the employee’s incapacity for work, you can count on compensation from the employer for temporary loss of ability to work. It will be 100% of monthly earnings and can be either one-time or monthly. Insurance payments for work-related injuries can also be temporary or regular. Finally, the employee is also entitled to compensation for moral damages. However, to receive this type of payment, the employee must go to court. Moral damage is not included in the insurance amount.

How is the insurance amount calculated?

The amount of mandatory payment and compensation to the employee from the employer depends on the type of insurance contract, as well as the severity of the damage. For some professions, the amount of payments is regulated by legislation. For example, employees of the Ministry of Internal Affairs who, as a result of an injury, received a disability of the first group receive 1.5 million rubles, the second group - 1 million rubles, the third group - 5 thousand rubles. The insurance company makes the calculation.

Moderate injury

According to Article 111 of the Criminal Code, the following damages and disorders are considered to be of moderate severity:

• long-term health disorder of the employee (work capacity lost for more than 21 days);
• permanent loss of the employee’s general ability to work by less than one third.

Remember that in order to receive payment for this type of damage, the employee must see a doctor.

Compensation for lost earnings due to a work injury for an employee

According to the Labor Code, payment for lost earnings for an employee from the employer will occur according to sick leave. After the incident, the employee received treatment and was unable to work for some time; he is entitled to 100% compensation for absenteeism. If at the end sick leave worker returns to work, then, as a rule, compensation is expressed in the fact that the employee receives from the employer at the end of the month his standard monthly salary without any deductions. Or several months’ salary at once, if the work injury was serious. Remember that the employer does not have the right to deduct money for sick leave.

How much is a lump sum payment to an employee in case of injury?

A one-time payment to an employee from an employer means compensation medical expenses in case of production damage. If we are talking about a serious injury with long-term disability, for example, an eye injury, then the employee can count on compensation from the employer or the Social Insurance Fund for monthly compensation. And a one-time monetary compensation applies exclusively to measures that are necessary in order to restore the employee’s health to the maximum extent possible. It is easy to calculate from documents. The calculation procedure is very simple, we discussed it above.

Monthly insurance payment in case of accident

Many services in the area health insurance make it possible to prevent unplanned expenses associated with an accident. Various bodily injuries occur quite often.

The policy helps prevent the consequences of an accident. And, if a client of an insurance company has suffered health damage, he should know what documents are needed to obtain insurance after an injury.

Bodily injuries covered by insurance are classified as accidents because they do not depend on the will of the victim.

If the incident led to death, this will apply to a different type of protection - life insurance.

An accident occurs suddenly and provokes a violation of the integrity of the human body, disruption of its functioning or limitation of functioning.

The list of common injuries covered by insurance claims includes the following:

• bone fractures;
• tissue bruises, hematomas, nerve ruptures, tendon damage, dislocations;
• damage to internal organs due to a fall or impact, in particular the organs of vision and hearing, their complete or partial loss.
• frostbite and burns;
• surgical interventions performed as a result of injury.

A more detailed list is compiled by a specific insurance company indicating the percentage of final amount payments under the contract.

Kinds

Insurance is divided into two main types:

1. Mandatory. The law assumes compulsory insurance from accidents for specific categories of citizens: military, court personnel, law enforcement agencies and the Ministry of Emergency Situations. It comes into force in case of complete or temporary loss of ability to work.
2. Voluntary. This type allows the policyholder, when concluding a contract, to choose the risks against which he wants to insure.

Mandatory social insurance certain categories of citizens are regulated by RF Law No. 4015-1.

Voluntary insurance has two forms: collective (group) and individual.

Collective insurance is provided by the employer to its employees.

Individually involves concluding a contract individual and making contributions on their own, as a rule, it insures in case of injury at home.

A type of individual accident insurance for persons leaving their place of permanent residence is also common.

When can I withdraw the money?

When an insured event occurs, it must be documented. It is necessary to foresee in advance what will be irrefutable evidence of injury.

It is not necessary, but it is advisable to prepare a photo or video from the scene.

The main documents confirming damage to health will be medical certificates.

It’s good if the victim or people from his environment - colleagues, relatives - call insurance company immediately after the incident.

So can be obtained from the operator exhaustive list supporting documents in a specific case. This will also serve as a positive factor in resolving the issue of payments.

A written application and other documents must be submitted within a reasonable time stipulated by the contract. According to Article 961 of the Civil Code of the Russian Federation, the period must be set at least 30 days.

After the insurance company has received and reviewed all documents and facts in the case, she has 14 days to make a decision regarding payments.

The insurance company notifies the policyholder in writing of the decision. Additionally, the insurer can send a notification via SMS or email.

If the answer is yes, The payment amount is transferred to the account specified by the client during registration within a week.

If the insured was the employer in a collective case, the insurance company will send the payment to the company’s account. In turn, the organization will transfer it to the employee.

Depending on the type of contract, payment can be made as a percentage of the severity of the harm to health and the period of validity of the certificate of incapacity for work.

The amount of insurance payment is calculated individually and approved by the insurance company before signing a contract with the client.

How do you feel about personal injury insurance benefits in the event of an accident?

Poll Options are limited because JavaScript is disabled in your browser.

I think insurance is a waste of money because it is very difficult to get a payment. 76%, 22 vote

I am sure that only scammers do not receive payments. 17%, 5 votes

I guess insurance is profitable investment, because you can get a “tidy” amount. 7%, 2 vote

Required information

The list of documents that need to be submitted to the insurer after an injury is not extensive:

Medical confirmation of an injury is a document issued by a doctor licensed or state clinic, containing an accurate diagnosis of the injury.

Depending on the circumstances of the incident, it may be necessary additional documents. For example, if the injury is the result of an accident, a copy of the report may be required. administrative offense or decisions on the involvement of participants in the accident, other certificates from the traffic police.

If the accident occurred as a result of illegal actions of third parties, for example, during an attack, a certificate from the local police officer may be required.

If the accident occurs at the workplace, personnel services must draw up an act confirming this event.

When collecting and preparing certificates and necessary documents To confirm the occurrence of an accident, one must be guided by the principle of reasonableness.

It is better to collect evidence on all aspects of the event, evidence must prove the fact, reasons and circumstances.

It is advisable to proceed from the interests of the insurer, whom the collected arguments in the form of documents and evidence should convince and leave no doubt about the reality of what happened.

Pay

The amount of payments often gives rise to disputes between the insurer and the policyholder. This is due to the ornate structure of the contract.

The first thing you need to understand right away is the amount of the maximum payment is determined by the contract. That is, if the amount necessary treatment will exceed maximum limit, then the full payment will be made sum insured.

Second, payment for each type of injury is determined as a percentage of the maximum insurance payment.

This means that if you get a broken leg, the payment can be, for example, up to 40% of the insured amount. And with a broken arm, only 20%.

Consequently, even if the insured amount is specified in the contract, such as 300,000 rubles, if a leg is broken, the insured will receive only 40% of this amount - 120,000 rubles.

Moreover, 120 thousand rubles. - This maximum payout for this particular injury. Fractures vary in complexity. And this fact also has an impact on the amount of compensation.

Third, if the insured event relates to several items, the payment for them is summed up. However, even in this case it should not be more than the total established amount.

What events will not be paid for?

It must be taken into account that regardless of the severity the injury will not be paid if it occurred under the following circumstances:

• committing illegal actions;
• being under the influence of alcohol or drugs;
• intentional self-harm;
• in case of an accident, if the policyholder was the culprit (unless otherwise provided by the contract).

Damages of a repeated nature are also not subject to payment, for example, repeated fractures of bones that did not fall within the contract period when they first occurred, or dislocations of previously received injuries.

A complete list of grounds for exempting the insurer from payment insurance compensation provided for in articles:, and 964 of the Civil Code of the Russian Federation.

If a refusal is received or disagrees with the amount of compensation, the insured person may file a claim or go to court.

What to do if you refuse?

The grounds for refusal are conventionally divided into two groups: legal and illegal.

TO legitimate reasons refusals include the following:

1. Non-compliance of the insured event with the terms of the contract.
2. Intentional provision of incorrect information (forgery of documents or use of false ones).
3. Violation of specific provisions of the contract (for example, it may indicate that compensation is not due for work-related injuries that were received while working overtime).

The concept itself insurance risk defined in Art. 9 of the Law of the Russian Federation “On the organization of insurance business”.

This article contains a section “About accident insurance”, where it is defined full list, definition and documents sufficient for proof.

Illegal grounds:

1. Missing the deadlines specified in the contract if there is a good reason for this (staying abroad, inability to submit an application due to the complexity of the injury).
2. Incorrectly drawn up application for payment (it must be checked by a representative of the insurer along with the documents before they are accepted).
3. Incomplete package of documents (this is almost always a disputable fact).
4. Lack of diagnosis in the insurance compensation payment table.

If the insurer refuses to pay insurance in case of injury, the client will be forced to go to court.

The fine is provided for by the clarifications of the Plenum of the Armed Forces of the Russian Federation dated June 28, 2012. No. 17. The fine is collected in favor of the plaintiff and amounts to 50% of the amount of the claim. Which can be a significant argument in filing a claim.

Review of judicial practice

Before preparing the contents of the statement of claim, it is advisable to familiarize yourself with the practice of the courts on the issue of payments for an insured accident.

Moreover, practice in this issue often on the client side - the policyholder.

Solution #1

The plaintiff filed a lawsuit against SK LLC Rosgosstrakh Life, because the insurer refused to pay him insurance compensation.

The refusal was due to the fact that they did not detect any signs of damage on the x-ray.

However, the court sided with the plaintiff and ordered the insurance company to make a payment of 100,000 rubles.

Solution #2

The plaintiff filed a claim against the LLC VTB Insurance, since the insurer refused to pay him due to the fact that the established diagnosis was not provided for in the insurance payment table.

The court satisfied the plaintiff’s demands and ordered the insurance company to pay 288 thousand rubles. for injury and 145 thousand rubles. as a penalty for refusal to voluntarily satisfy the plaintiff’s demands. In total, the plaintiff received 454 thousand rubles. for a broken collarbone.

In contact with

The health and life of military personnel is a mandatory subject state insurance. In the event of injuries or other damage related to the performance of official duties, officers receive monetary and social guarantees. The obligatory nature of insurance payments for military personnel is explained by the fact that their work almost always involves risks to health and life.

Legislative regulation and final recipients

Required documents

To obtain insurance, the beneficiary will need:

• passport;
• statement;
• documentary evidence of the insured event, certified by the command of the military unit;
• certificate of disability (if available).

In the event of the death of an officer, the list is supplemented:

• death certificate or medical certificate;
• the conclusion of the military medical commission on the existence of a cause-and-effect relationship between the death and service obligations;
• command report on the exclusion of a serviceman from the list of personnel;
• documents confirming relationship with the deceased.

In the event of the death of a beneficiary, his heirs must provide documents proving their relationship with both deceased persons.

All specified information is transferred to the insurer in the form of copies certified by the signature and seal of the head of the military unit or military registration and enlistment office.

Where to get document forms

The beneficiary himself should not be puzzled by this issue. Since, at his request, the leadership of the military unit independently provides certificates of insured events that occurred during service or military training. These include information:

• about death;
• about receiving disability;
• about receiving a serious injury or concussion;
• about damage to the health or death of a person liable for military service during training;
• about unfitness or limited fitness as a result of injury or illness resulting from service or training.

In some cases, this list is supplemented by a report on the fact of the officer’s death, documents from an official, administrative or criminal investigation. Provided that the investigation into the case is completed by a ruling of the court, investigator or other authorized person that has entered into legal force.

Compensation payment deadline

The company pays the insurance 15 days after receiving documents from the beneficiary. In case of delay, the insurer, at its own expense, is obliged to pay a penalty in the amount of 1% of the amount due for payment.

Insurance indexation

The amounts of insurance payments to military personnel are subject to mandatory annual indexation in order to “mitigate” the effects of inflation. In January 2019, the President prepared a decree according to which the sizes of all social payments and compensation will increase by 2.5%. The decree will come into force at the beginning of February 2019.

When the insurance company refuses to pay

The insurer refuses to pay the beneficiary if the insured event:

• occurred as a result of unlawful behavior of a military personnel;
• occurred at a time when the insured was in a state of alcoholic or narcotic affect;
• was the result of intentional harm to health, which the citizen inflicted on himself, provided that this circumstance is proven in court.

The decision to refuse payment is made in writing, signed by the head of the insurance company and transferred to the beneficiary within a reasonable time after adoption. The document must state the reasons for the refusal, the possibility of eliminating or appealing them.

Procedure for registration and payment of insurance

Compensation is paid exclusively in the territory Russian Federation. The methods may vary depending on the terms of the specific agreement:

• at one time or in parts;
• cash or non-cash transfer.

Payment processing begins with collecting a package of documents. Most of them, as we have already said, are prepared by the command of the military unit to which the injured or deceased serviceman is attached.

To initiate the preparation of certificates, the insured or beneficiary writes a corresponding report (application) to the command. In the event of the death of an officer, his close relatives turn to the command with a statement.

After collecting and generating certificates, the command sends them along with an application (report) to the insurance company. Here, the analysis of documents and situations takes 10 working days, i.e. 2 weeks.

If inaccuracy or errors are detected, insurers return the package with a covering letter stating the reasons for the return. After the violations are eliminated, the serviceman or his relatives are paid the amount of compensation established for a specific insured event. As a rule, no more than 1-2 days pass between the end of the review and the transfer of funds. In case of delay, the company pays the victims a penalty in the amount of 1% of the insurance.

Procedure for appealing a refusal

In the event of a refusal to pay insurance for an injury or other damage to health, a serviceman has the right to appeal it in court. This is a long and labor-intensive procedure, so we will only talk about it briefly.

So, disputes regarding insurance payments take place in the generally established manner. However, before you submit statement of claim to court, the beneficiary must take measures to voluntarily resolve the issue. Why is it necessary to send a letter to the company demanding payment of insurance and its detailed justification. Almost always, such claims remain unanswered or their authors receive a reasoned refusal.

After receiving a response, the citizen can file a claim in court, to which are attached:

• plaintiff's passport;
• a copy of the insurance company's decision to refuse;
• a copy of the pre-trial claim;
• a copy of the response thereto;
• power of attorney for a representative if he participates on behalf of the plaintiff;
• documentary evidence on which a party bases its claims.

Most often, multiple examinations are used as evidence - medical, technical, psychological-psychiatric and others. The most important difficulty that the plaintiff will face at the examination stage is the statute of limitations of the insured event.

Everyone knows that the more time passes from the moment of an event, the more difficult it is to analyze it and establish the objective truth. However, if the expert was still able to answer the questions posed, and the court took his opinion into account, there is a possibility of a positive outcome of the case.

Regulatory acts regulating the issue

1. user is the response to
   his question

   Lawyer contacts
   with the user and
   provides him
   consultation

Among injuries to internal organs and limbs, the most common case is bruise. It can be the cause of some damage, or it can be an independent injury. You can bruise not only your arm or knee, but also various soft organs. At first glance, this is a fairly harmless case; it does not seem as scary as a fracture. But in fact, the consequences of such damage can be negative and lead to protracted illnesses if the severity of the injury is not detected in time. Cases are different, but each requires diagnosis and attention from doctors. This is why it is worth taking out an insurance policy to protect against injuries and accidents. Cases of bruises are considered in insurance contract individually.

What is a bruise

You can bruise any part of the body, including internal organs. This means damaging tissues and small vessels without destroying the integrity of the skin and the tissues themselves. Bruises are often combined with sprains, abrasions, etc. The first sign of such damage is a bruise, hematoma and then a slight swelling of the bruised area. In medicine, bruises are assigned different degrees, depending on how badly the victim damaged a particular part of the body. There are four degrees of bruises.

The most severe is the fourth, when changes in the affected organ interfere with the normal functioning of other organs and systems of the human body. Do not think that such an injury is trivial and does not require treatment. If you damage the knee or other hard place on the body, then in addition to a hematoma or as a consequence of it, necrosis and tissue rejection may occur. An injured joint becomes non-functional for a long time, taking a person out of the usual rhythm of life. It is difficult to say immediately whether treatment will be required and how complex it will be. Therefore, an insurance policy can be useful in any case. If you hit your head, it is worth checking to see if you have suffered a concussion. And this is a serious injury.

Compensation for injuries

In accordance with the payment table, if you bruise an organ or limb, you will be compensated from 3 to 10%, depending on the area that was damaged by the victim.

In order to receive compensation for insured event, you must first write a claim to the insurance company for payment. There is a clear deadline for filing an application in the contract itself. It is also necessary to submit documents such as certificates from a medical institution where you recorded the fact of injury and received treatment. The insurance company may request other documents if necessary. The payment is not made to the applicant, but as payment for treatment medical institution. Don't delay contacting your insurance company.

The policy will not directly protect against injury, but it will allow you to avoid unnecessary expenses when dealing with the consequences. The insurance guarantees payment of compensation to the victim for material costs during treatment. Protecting life and health from accidents allows you to choose for each person for each case individual conditions and include the necessary risks. Depending on the number, type of damage, and their severity, the amount of payments under the policy is calculated. For ease of calculation, a single table of payments for injuries has been developed.

Injuries such as bruises, along with fractures and injuries, are described in the table of payments for insurance claims in great detail, which gives insurance companies clear instructions when calculating the amount for compensation.