Accident Insurance
Accident Insurance: 3 technical terms explained – definition, synonyms and legal basis.
Occupational Accident
Synonyms: Work accident, Industrial accident
An occupational accident is an insured event under statutory accident insurance suffered by covered persons as a result of their work or insured activity.
Concept
An occupational accident is an insured event under statutory accident insurance. It covers accidents suffered by insured persons – particularly employees, but also other groups such as self-employed farmers, pupils, students, or volunteers – as a result of their work or insured activity.
Characteristics and Requirements
The accident must be a time-limited event, occurring within a single work shift, and must act on the body from outside such that it causes bodily injury or death. Damage to an aid, such as glasses, during its intended use can, under certain conditions, also qualify as an occupational accident.
Significance
In Germany, statutory accident insurance is funded exclusively by employers and, upon a recognized occupational accident, covers medical treatment, rehabilitation, and, where applicable, pension benefits, regardless of employer fault.
Disability (Invalidität)
Synonyms: Invalidität, Permanent Disability
Disability is the permanent, usually accident-related impairment of a person's physical or mental capacity, which represents the central triggering event for benefits under accident insurance.
Concept
In accident insurance, disability refers to the permanent, presumably lifelong impairment of an insured person’s physical or mental capacity resulting from an accident. It must be distinguished from temporary health impairments and represents the central triggering event for benefits under classic accident insurance.
Time Limits and Proof
Policy conditions typically provide for time limits within which disability must occur (e.g., within one year of the accident) and must be medically established and reported to the insurer (e.g., within 15 months). These time limit provisions serve to distinguish accident-related causes of impairment from illness-related or degenerative causes.
Distinction from Related Concepts
Disability within the meaning of accident insurance must be distinguished from occupational disability (inability to perform one’s most recently exercised occupation) and incapacity for gainful employment (general inability to work), which each represent distinct insurance law concepts with different benefit conditions and calculation methods.
Degree of Disability (Invaliditätsgrad)
Synonyms: Invaliditätsgrad, Percentage of Disability
The degree of disability is the percentage of permanent impairment of physical or mental capacity, determined under accident insurance using a scale of limb values or a medical assessment, which governs the amount of the disability benefit.
Concept
The degree of disability is the percentage extent to which an insured person’s physical or mental capacity is permanently impaired following an accident. It is determined based on a medical assessment and, for standardized injuries to limbs and sensory organs, using a contractually agreed scale of limb values.
Determination Using the Scale of Limb Values
For the loss or complete loss of function of certain body parts (e.g., an arm, an eye, a leg), the policy conditions set fixed degrees of disability, enabling standardized and legally certain benefit assessment. For impairments or partial impairments not covered by the scale of limb values, assessment is performed individually based on a medical opinion.
Relevance for Benefit Calculation
The amount of the disability benefit paid generally results from multiplying the determined degree of disability by the agreed sum insured; many tariffs also provide for a progression under which higher degrees of disability lead to a disproportionately higher benefit, in order to appropriately account for particularly severe impairments.