Medical Expenses in Accident Insurance (Heilungskosten)

Concept

Medical expenses comprise the cost of appropriate treatment of the consequences of an accident: outpatient treatment by doctors, dentists and chiropractors, medicines and analyses, stay and treatment in the general ward of a hospital, follow-up and spa cures, aids for physical injuries and functional loss, and necessary travel, transport and rescue costs. The term Heilungskosten is customary in Switzerland; Germany speaks of Heilkosten and Austria of Unfallkosten.

Statutory Benefit and Private Supplement

In Switzerland medical expenses are a statutory benefit of mandatory accident insurance under the UVG (Art. 10 et seq.), provided by the accident insurer in kind without deductible or co-payment; health insurance under the KVG steps in only where no UVG cover exists, for instance for non-employed persons or part-time employees working fewer than eight hours per week. Private supplementary covers extend the statutory benefits to semi-private or private wards, free choice of doctor and treatment abroad. An example from practice: UVG supplementary wordings pay the portion of effective, appropriate and economical treatment in the insured hospital ward not covered by KVG or UVG, first treatment abroad, aids, transport and rescue and recovery costs up to a limit (e.g. CHF 50,000), and add contributions to complementary medicine and domestic help; deductibles and co-payments of other social insurers remain excluded. In Germany, statutory and private health insurance together with statutory accident insurance bear medical treatment; private accident insurance knows medical expenses only as a subsidiary add-on outside the model conditions. In Austria the AUVA provides accident medical treatment for occupational accidents, while private accident insurance reimburses “accident costs” including medical expenses, rescue costs and cosmetic surgery up to the agreed sum, to the extent no social insurance carrier pays.

Practical Relevance

In all three markets, medical expenses under private accident insurance are subsidiary benefits: they respond only after social or health insurers have paid and typically cover deductibles, non-recognised treatments and comfort services. In group personal accident schemes and international programmes it must be checked whether primary medical expense cover is required for assignees or persons without local social insurance, since the accumulation of expense and capital benefits materially drives the claims burden.