Cosmetic Surgery after an Accident (Kosmetische Operationen)
Cosmetic surgery after an accident is a benefit module of private accident insurance that reimburses, up to the agreed sum, the costs not borne by third parties of medical procedures to correct an accident-related impairment of the insured person's outward appearance, including dental treatment of incisors and canines.
Concept and Preconditions
The module covers procedures that are not strictly medically necessary but are intended to remove or mitigate a disfigurement caused by the accident – scars, facial injuries, loss of visible teeth. Under the German model conditions (section 2.7 AUB 2020) the operation must be performed by a doctor after completion of medical treatment, within three years of the accident for adults and before the age of 21 for minors. Reimbursable items are doctors’ fees and other surgical costs, necessary hospital accommodation and board, and dental treatment and denture costs, with only incisors and canines counting towards outward appearance.
Subsidiarity and Market Practice
The benefit is subsidiary: it requires that no third party – health insurer, liability insurer of a tortfeasor – is obliged to reimburse the costs or that such party disputes its liability. In Austria cosmetic surgery is reimbursed as part of “accident costs” alongside medical and rescue costs up to a common sum insured. In Switzerland mandatory accident insurance pays only for appropriate treatment of the consequences of the accident; purely aesthetic corrections are left to private supplementary covers, although the line between reconstructive and cosmetic surgery is fluid in practice. Sums insured typically fall in the low to mid five-figure range. Examples from practice: group tariffs based on the AUB expressly treat dental treatment and dentures after accident-related tooth loss as cosmetic surgery and require that no third party is obliged to reimburse; premium individual tariffs reimburse doctors’ fees, hospital costs and dentures up to a combined EUR 50,000.
Practical Relevance
For advisory purposes the module is relevant chiefly for children, occupations with facial exposure and leisure risks involving facial and hand injuries. At claims stage the time limits and the question of whether a procedure belongs to medical treatment (medical expenses) or to cosmetic correction are decisive, because the priority of health insurance depends on that classification.
Legal basis
- CH: Art. 10 UVG (appropriate medical treatment)