Basic principles of insurance from an accident are:
state parity, representatives of insured persons and employers in the management of accident insurance;
timely and full refund damage by the insurer;
compulsory insurance against accidents for persons who work on the terms of an employment contract (contract) and other grounds provided for by labor legislation, as well as the voluntariness of such insurance for persons who provide themselves with work on their own, and citizens - subjects of entrepreneurial activity;
provision of state guarantees realization of their rights by the insured citizens;
obligatory payment of insurance premiums by the insured;
formation and spending of insurance funds on a solidary basis;
differentiation of the insurance rate, taking into account conditions and the state of labor safety, industrial injuries and occupational morbidity at each enterprise;
economic interest of subjects of insurance in improving working conditions and safety;
target use of accident insurance funds.
The subjects of accident insurance are insured citizens, and in individual cases- members of their families and other persons, policyholders and the insurer.
The insured is a natural person, in the interests of who is insured (hereinafter referred to as the employee).
Employers are insured and, in some cases, insured persons.
Insurer - Fund social insurance from accidents at work and occupational diseases of Ukraine (hereinafter referred to as the Fund for Social Insurance against Accidents).
Accident insurance object case is the life of the insured, his health and ability to work.
In accordance with this Law, an employer is considered to be: a legal entity (enterprise, institution, organization) or a natural person who, within the framework of labor relations, uses the labor of natural persons.
Compulsory insurance against accident are subject to:
1) persons who work on the terms of an employment contract(contract) or on other grounds provided for by labor legislation;
2) pupils and students of educational institutions, clinical residents, graduate students, doctoral students involved in any work for a while, before or after classes; during classes, when they acquire professional skills; during the period of industrial practice (internship), performance of work at enterprises;
3) faces which are contained in correctional, medical labor, educational- labor institutions and are involved in labor activity in production in these institutions or at other enterprises under special contracts.
Causing harm to the fetus as a result of an injury at work or an occupational disease of a woman during her pregnancy, in connection with which the child was born disabled, is equated to an accident that happened to the insured. Such a child, in accordance with the medical examination, is considered insured and up to 18 years of age or until graduation, but no more than until he reaches 23 years of age, assistance from the Social Accident Insurance Fund is provided.
Article 10. Employee insurance procedure
Work accident insurance does not require the consent or application of the employee. Insurance is carried out in an impersonal form. All persons listed in Article 8 of this Law are considered insured from the moment this Law comes into force, regardless of the actual fulfillment by the insurers of their obligations regarding the payment of insurance premiums.
All insured persons are members of the Social Accident Insurance Fund.
Article 11 Voluntary insurance from an accident
Voluntarily from an accident can insure:
1) individuals who are self-employed- are engaged in advocacy, notarial, creative and other activities related to the receipt of income directly from these activities, members of a farm, a personal peasant farm, if they are not employees;
2) citizens - subjects of entrepreneurial activity.
3) priests, clergymen
Section 12. Accident Insurance Certificate
Persons subject to accident insurance are issued a certificate of compulsory state social insurance, which is the same for all types of insurance.
Article 13. Insured risk and insured event
Insured risk - circumstances, as a result of which an insured event may occur.
An insured event is an accident at work or an occupational disease that caused an occupationally predetermined physical or mental injury to the insured person under the circumstances specified in Article 14 of this Law, upon the occurrence of which the right of the insured person to receive material security and / or social services arises.
An occupational disease is also an insured event if it is established or revealed during the period when the victim was not in labor relations with the enterprise where he fell ill.
Violation of labor protection rules by the insured, which caused an accident or occupational disease, does not release the insurer from fulfilling obligations to the injured.
The basis for paying the victim the costs of medical care, medical, professional and social rehabilitation, as well as insurance payments is an act of investigation of an accident or an act of investigation of an occupational disease (poisoning) in accordance with the established forms.
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Thus, the OSS Institute for Occupational Accidents and Occupational Diseases provides, in addition to compensation payments, a whole range of insurance services related to accident prevention mechanisms, training programs for training personnel for safe work, as well as the provision of medical and rehabilitation assistance to victims at work.
The subjects of relations under OSS against accidents at work and occupational diseases are the insured persons (employees), the insured and the insurer.
The most important functions of insurance against accidents at work and occupational diseases are:
The insured person, in case of damage to his health and ability to work, is compensated for the loss wages and reimburse the cost of medical care, as well as organizing medical, professional and social rehabilitation programs aimed at the maximum possible restoration of working capacity and providing opportunities for professional retraining and employment. Thus, the insurer, represented by its specialists, organizes comprehensive social protection of injured persons with the help of compensation payments, medical and rehabilitation assistance.
Another function of the insurer is to identify and analyze typical mass occupational risks of occupational injuries and occupational morbidity. To this end, the insurer's specialists have a staff of highly professional technical inspectors and medical workers who carry out systematic checks for the presence of risk factors in the workplace and in production. These employees have the right to issue instructions to employers in order to eliminate violations of safety rules in the operation of machinery and equipment and the organization of work.
Assessment, identification and prevention of risk situations can best be organized with the specialization of technical inspectors and medical workers in the same type of industry and production, the use of modern diagnostic devices, methods and procedures, the capabilities of research centers and laboratories to identify design flaws in equipment and risk factors available in technological processes.
The control function of the insurer includes in its arsenal of means:
An extreme measure against insurers (employers) for violations of the rules of safe activities at work is the establishment of increased insurance premiums for them, which financially burdens them and requires a change in their attitude to safe activities.
The most serious tool for influencing individual employers who allow gross and often deliberate actions that result in accidents at work is the refusal to reimburse them for the costs of accidents through insurance mechanisms. The imposition on them of the costs of compensation for harm to employees, if the cause of the accident was gross negligence on the part of the employer, emphasizes an uncompromising position towards malicious violators of safe labor activity.
Another area of preventive activity of the insurer in the field of assessing and minimizing professional risks is the formation of “anti-risk behavior” among the personnel of enterprises. To do this, the insurer's specialists carry out extensive educational work at enterprises to explain to employers and employees the physical, chemical, biological and psychological nature of occupational threats. It is believed that employers and employees will correctly perceive the requirements safe work and respond to potential dangers through not only administrative and repressive measures, but on the basis of understanding the nature of the manifestation of risks, the formation of motivational attitudes and an internal culture of safe behavior at work.
Students, graduate students, young scientists who use the knowledge base in their studies and work will be very grateful to you.
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Introduction
insurance accidental damage payment
Insurance as a field financial activities It arose from the division of social labor and developed as a person realized the value of his life, health and property.
In the context of the transition to a market economy, insurance is one of the fastest growing industries economic activity. Market economy, and especially the non-state sector National economy, makes demand for various types of insurance, since private property, unlike state property, needs comprehensive insurance protection. She does not have financial guarantees from the state behind her and wants to protect herself from the consequences of possible risks.
Insurance is one of the oldest and most stable forms of ensuring economic life, rooted in a distant history. Insurance is carried out on the basis of contracts of property or personal insurance concluded by a citizen or legal entity (insured) with an insurance organization (insurer). At its core, insurance is the creation of trust funds Money, designed to protect the property interests of the population in private and economic life from natural disasters and other unforeseen accidental extraordinary events in their nature, accompanied by damage.
In society, insurance plays the role of a mechanism that redistributes financial resources(insurance fund) from all members of society to those who need financial assistance as a result of accidents that have happened to them. Unlike social insurance, where most or all citizens are insured, in commercial insurance redistribution occurs only among the members of a particular insurance fund who paid insurance premiums to it.
Accident insurance is the most traditional type of personal insurance for insurance practice. The main purpose of accident insurance is to compensate for damage caused to the health and life of the insured as a result of an accident.
Accident insurance is a traditional type of life insurance, the content of which has recently changed due to the inclusion of additional insurance coverage in the form of life-threatening illness insurance, thus the full modern name of this type is accident and illness insurance. The main purpose of accident insurance is to compensate for damage caused to the health and life of the insured as a result of an accident or illness.
1. Item withinsurance and insurance coverage
1.1 History of accident insurance
Accident insurance has undergone significant changes over the years of market reforms. They are associated with the introduction of compulsory types of insurance against accidents for certain categories and groups of the population, the development of collective forms of insurance for employees of enterprises and organizations, the emergence and rapid spread of such a new type of insurance for domestic practice as insurance of citizens traveling abroad.
In the classification of types of insurance activities given by Rosstrakhnadzor in the Terms of Licensing Insurance Activities in the Russian Federation, traditional accident insurance is replaced by accident and illness insurance and is defined as “a set of types of personal insurance that provide for the insurer’s obligations for insurance payments in a fixed amount, or in the amount of partial or full compensation for the additional expenses of the insured, caused by the onset of insured event". As practice shows, in most cases, insurers limit their liability only to accidents, leaving the risk of disease in the competence of health insurance and life insurance.
The main purpose of accident insurance is to compensate for damage caused to the health and life of the insured as a result of an accident.
Accident insurance dates back to the 19th century. Its appearance is largely associated with the emergence and development of railway transport. However, the idea of accident insurance was known much earlier. The 1541 law of the sea of Wisby required the owner of a ship to insure his captain's life against accidents. In Holland, already in 1665, there was a report card for the loss of various members of the body for a mercenary army. In the 18th century, mutual aid alliances were created in Germany in case of fractures. In the 19th century, this type of insurance began to develop in England, where rail links appeared earlier than other countries.
Labor legislation has played a major role in the development of accident insurance in Russia. Under the pressure of the labor movement and the acceptance of European states by the law of June 2, 1903. Rules on remuneration of victims of accidents of workers and employees, as well as members of their families, in enterprises of the factory, mining and mining industry were adopted. This document introduced the obligation of the employer to compensate for the harm caused to the employee as a result of an accident at work, in the form of temporary disability benefits (50% of earnings), compensation for medical expenses, the appointment of a disability pension and a survivor's pension, as well as the payment of a fixed funeral benefit.
In 1912, as part of a whole package of documents that introduced compulsory insurance of employees, a more advanced document was adopted - the Law and the Appendix on insurance of workers against accidents. Compulsory insurance against accidents extended to all workers employed in factories and mining enterprises, in shipping and in railway transport private use and some others.
Except compulsory insurance widely developed in pre-revolutionary Russia and voluntary forms of insurance against accidents. They were engaged in both large joint-stock companies and mutual insurance companies.
In Soviet times, compulsory insurance against accidents at work was introduced into the social insurance system, and its implementation was entrusted to a specially created state Social Insurance Fund, which until the early 1990s. unions ruled.
Voluntary insurance against accidents was carried out by Gosstrakh. This type of insurance was the most popular in the field of personal insurance.
During the market reforms of the 1990s. The scope of accident insurance has expanded significantly: it provides the insured and their family members with comprehensive protection against the economic consequences of disability or death resulting from unforeseen and random events.
The practice of accident insurance shows that it can be carried out in various forms, while maintaining a single socio-economic content. Currently, in the Russian Federation, accident insurance can be mandatory, carried out by virtue of law, or voluntary, carried out on a commercial basis.
1.2 The concept of an accident
Insurance is carried out on the basis of a personal insurance contract concluded by a citizen or legal entity
An accident is understood as a sudden, external, unforeseen impact on the human body, the result of which is harm to the health of the insured.
"Suddenness" means that the accident must be a relatively short-term event (this does not apply to its consequences, i.e. harm to the health of the victim).
If a person has been exposed to harmful environmental effects for a long time, then these effects cannot be classified as an accident.
In the same way, the deterioration of health due to excessive exertion for a long time, for example, when playing sports, cannot be considered as an accident.
Sunbathing, the vacationer fell asleep and received severe burns.
There is no sign of suddenness, since the effect of the sun on the human body was gradual.
The skier ran into a tree, fell and was injured.
Hitting a tree should be classified as a sudden action.
The concept of surprise also includes elements of the unexpected, the unforeseen, and the inevitable. This means that in certain cases an event lasting for a relatively long time can be considered as sudden.
For example, as an accident, the death of the insured should be classified as a result of prolonged inhalation of poisonous gases from a faulty furnace, if he could not notice the leakage of gas, which has neither color nor smell, or did not have time to do anything, because he lost consciousness.
The external nature of the impact.
Human exposures classified as accidental can be mechanical, chemical, thermal and electrical. Organic and functional changes that occur in the human body throughout its life are internal influences, such as a stroke or heart attack, and do not belong to this category of events. People's own actions can also be considered as an external influence.
Impact on the human body
Under the influence, classified as an accident, insurance understands both a natural phenomenon, such as fire, ice, and the actions of the people themselves, which are harmful to their health.
continuous nature
The impact on the human body in insurance is considered as an accident only on the condition that as a result of its occurrence the health of the insured was unforeseen harmed. Suicide and self-inflicted bodily injury by the insured are not included in the insurance coverage.
It should be emphasized that the sign of unforeseeability does not refer to an event, but to the harm caused to the health of the insured person as a result of its occurrence. As unintentional, harm to health caused as a result of self-defense or in an attempt to save a human life should be considered. Events that occurred as a result of gross negligence of the insured person as a result of its occurrence.
As unintentional, harm to health caused as a result of self-defense or in an attempt to save a human life should be considered.
Events that occurred as a result of the gross negligence of the insured person are also recognized as an insured event if the insurer cannot prove that the harm to health was caused intentionally.
Damage to the health of the insured
An external impact on the human body is an accident if the immediate result of this event is harm to the health of the insured in the sense of violating the anatomical and physiological integrity of the body. Therefore, property damage caused by external influence on the insured, such as damage to limb prostheses, dentures or glasses, is not subject to compensation under this type of insurance. For payment insurance compensation it does not matter what kind of harm was caused to the health of the insured. The term "harm to health" is not limited in meaning to direct bodily injury. It is sufficient if, as a result of external influence, the insured has suffered a mental trauma, which can be expressed in nervous excitement, shock, anger, etc.
It is important to emphasize that in order to recognize an event as an insured event, there must be a causal relationship between the accident, harm to the health of the insured and the damage subject to insurance compensation. The burden of proof is placed on the insured by law.
Accidents are also considered to be events in which, due to physical overexertion, the insured person experiences a dislocation of the spine or joints of the extremities, or stretching or tearing of muscles, tendons, ligaments or joint capsules.
Thus, an accident is recognized not only as damage caused to the health of the insured as a result of a sudden external impact, but also as a result of excessive physical exertion. This refers to the conscious actions of the insured himself, leading to excessive exertion of forces, which, in turn, harms his health in the form of dislocations, sprains and ruptures.
Damage to the intervertebral discs and meniscus, related to age-related changes in the body, but manifested after strong physical exertion, are excluded from insurance coverage. This is because, from an anatomical point of view, the intervertebral discs and meniscus are cartilage, and not tendons, ligaments, muscles, or a joint bag. Therefore, this coverage extension only applies to typical sports-related injuries.
Exclusion from insurance coverage
There are two groups of exceptions: certain events and certain types of damages.
Exceptions to insurance coverage are the following events, which, by all indications, although they are an accident, but the consequences of which are not covered by insurance coverage.
Accidents resulting from mental disorders or disturbances of consciousness, including those caused by alcohol or drug intoxication of the insured person, as well as stroke, epileptic seizure or convulsions affecting the whole body. Insurance guarantees remain, however, if these disorders or seizures were caused by an event covered by insurance under the contract.
Accidents in which the insured person got into as a result of committing or attempting to commit unlawful acts.
Hostilities, civil wars and other internal disturbances, if the insured hosted or a civil war caught the insured person unexpectedly abroad, then the insured person is subject to insurance protection for this type of insurance within seven days.
Accidents that occurred to the insured while driving aircraft, including sports, or at the time of being in them as a crew member (if this is the professional activity of the insured). These risks can be included in the insurance coverage when concluding special insurance contracts through the German Aeronautics Society. In addition, some insurers now already offer appropriate additional coverage under voluntary accident insurance.
Racing competitions on motor vehicles. Insurance coverage does not apply not only to the driver, but also to other people in the cabin of the vehicle participating in the race.
Accidents caused by exposure to atomic energy. The exception is not only the damage caused by nuclear radiation, but also accidents as a result of explosions, a sharp change in pressure, due to a panic, etc.
Damage caused to the health of the insured as a result of the following events is excluded from the insurance coverage:
Damage caused by all types of ionizing rays is excluded from the insurance coverage. If radiation therapy is the cause of the disease, then the insurance cover is retained, provided that this therapy was prescribed for the treatment of the consequences of an accident insured under the relevant contract. Persons exposed to increased radiation exposure due to the nature of their activities can insure the risk of occupational disease by including appropriate clauses in the accident insurance contract or by concluding special insurance contracts.
Carrying out therapeutic measures and surgical intervention, if they were not caused by the need to treat the consequences of an accident.
For persons of certain professions associated with an increased risk of infectious diseases, for example, doctors, paramedical personnel, it is possible to include these risks in insurance coverage in cases where pathogens entered the body of the insured person through skin damage or by injection.
infectious diseases.
The insurance coverage remains, however, if the causative agent of an infectious disease has entered the body of the insured person as a result of injuries or injuries received as a result of an accident included in the insurance coverage under this contract. Minor damage to the skin and mucous membranes, through which pathogens could enter the body of the insured immediately or after a certain time, are not considered injuries as a result of an accident.
Infectious diseases are in the nature of a disease. That is why they are excluded from insurance coverage under accident insurance contracts. The liability of the insurer remains only in those cases when at the beginning of the chain of cause-and-effect relationships there is an insured accident and the causative agent of the disease enters the body of the insured person as a result of the damage caused by this accident. AIDS disease and its consequences are also excluded from the insurance coverage if the infection occurred through small lesions of the skin or mucous membranes.
Poisoning due to the ingestion of solid or liquid substances through the throat.
It should be emphasized that it is the ingestion of toxic substances into the body through the throat that is the main condition for exclusion from insurance coverage. If the insured inhales a poisonous substance or receives it as an injection, then the insurance coverage remains.
Receiving a poisonous substance through the throat also means that the insured himself takes actions through which it enters the body. It does not matter whether he acted voluntarily or under duress, consciously or in ignorance. If the poisonous substance entered the body of the insured through the actions of third parties, then the liability of the insurer remains.
An exception to the insurance coverage is provided by hernias of the linea alba and inguinal hernias, unless they have arisen as a result of a violent external influence on the insured.
The insurance coverage does not cover injuries of the intervertebral discs, as well as bleeding of internal organs, unless they were caused by an insured accident.
Nervous disorders, which are the mental reaction of the insured person to certain events, are also an exception to the insurance coverage.
Some companies insure accidents that occurred as a result of a violation of the insured person's consciousness due to alcohol intoxication. When driving, however, the maximum blood alcohol limit must not exceed 1.3%.
A number of insurers also offer insurance for the so-called passive risk of hostilities.
Types of insurance guarantees
Voluntary accident insurance pays for death offers a wide range of insurance guarantees, which are included in contracts by agreement of the parties. When concluding an insurance contract, the policyholder has the right to freely choose the type and amount of insurance coverage.
The most important guarantee provided by the insured against accidents is the guarantee of insurance payments in case of disability, which is necessarily included in the contract. Other types of guarantees are agreed at the discretion of the parties additionally. Disability insurance benefits include:
Death insurance benefits
Daily cash allowance
Daily allowance during hospital stay
Cash allowance during the recovery period, including payment for sanatorium treatment, space operations, etc.
1.3 Object and subjects of accident insurance
Accident insurance guarantees protection in the form of compensation in the event of an accident.
The object of insurance against accidents under Russian law are property interests the insured, related to disability or death due to an accident.
The main subjects of insurance relations are policyholders and insurers. Under a personal insurance contract, one party (the insurer) undertakes, for the fee stipulated by the contract (insurance premium) paid by the other party (the insured), to pay a lump sum or pay periodically the amount (sum insured) stipulated by the contract in the event of harm to the life or health of the insured himself or another named in contract of a citizen (insured person).
Legal entities and capable persons are recognized as insurers. individuals who have concluded insurance contracts with insurers or who are policyholders by virtue of law
Insurers - legal entities established in accordance with the legislation of the Russian Federation for the implementation of insurance, reinsurance, mutual insurance and licensed in accordance with the procedure established by this Law.
Insurers carry out insurance risk assessment, receive insurance premiums ( insurance premiums), form insurance reserves, invest assets, determine the amount of loss or damage, make insurance payments, carry out other actions related to the fulfillment of obligations under the insurance contract.
1.4 Insurance cover
Accident insurance offers four basic guarantees. However, in practice, insurers may use various combinations of these standard coverages or exclude some of them from private insurance terms.
Accident insurance guarantee system:
Basic guarantees:
Sum insured in case of death;
Sum insured in case of disability;
Daily allowance for temporary disability;
Payment of medical expenses for treatment;
Additional warranties:
survivor's pension;
disability pension;
Care allowance;
Payment of expenses for prosthetics and cosmetic surgery;
Payment of expenses for sanatorium treatment necessary for rehabilitation.
The Accidental Death Guarantee pays to the beneficiary named in insurance contract, or the heirs of the insured amount of money specified in the private insurance conditions. At the request of the insured, the capital can be paid in the form of rent (pension).
There are two approaches to determining disability rates . In the first case, insurance companies, based on their own statistical observations, develop tables that evaluate the loss of disability based on the complete loss or loss of functionality of various organs, or use state tables used to determine compensation for damage from industrial accidents.
Table 1. Coefficients for calculating disability in case of complete loss or functional unsuitability of body parts and sensory organs
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Complete loss or ultimate functional incapacity of a body part or sensory organs |
Disability rate, % |
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One eye |
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Hearing in one ear |
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Smell |
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Taste sensations |
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One arm at the shoulder |
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One arm above the elbow joint |
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One arm to elbow |
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One hand brush |
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One thumb of the hand |
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One index finger of the hand |
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One finger of the hand: middle, ring or little finger |
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One leg above mid-thigh |
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One leg to mid-thigh |
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One leg to the knee |
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One leg to mid-calf |
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One foot at the ankle joint |
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One big toe |
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One any other toe |
If within one year from the date of the accident as a result of it an irreversible deterioration in the physical or mental state of the insured (disability) occurs, then he is paid insurance compensation in the form of a certain amount of money, the amount of which depends on the degree of disability.
Such a broad definition of the concept of disability was not chosen by chance. On the one hand, the deterioration of all functions of the human body falls under it. On the other hand, such a definition, such a definition can be used in relation to insured persons of all age groups regardless of the nature of their activities.
Disability must be established by a doctor within three months after the expiration of one year after the occurrence of the accident, about which the insured is obliged to declare to the insurer in the prescribed manner.
The guarantee against temporary incapacity for work provides the insured with compensation in the form of a daily allowance for the period of treatment and rehabilitation.
The provision of this guarantee has significant features. Firstly, the amount of the benefit is set in proportion to the sum insured specified in the contract for the risk of temporary disability. The amount of the insured person's average daily labor income is taken as the maximum limit of the amount of the benefit. Second, the temporary disability guarantee usually contains a deductible expressed in terms of the number of first days of disability during which no benefits are paid. The most common is a seven-day franchise. Third, the temporary disability guarantee has a limitation on the length of the benefit period. This period is stipulated in the private insurance conditions and traditionally is 365 days.
The guarantee of payment of medical expenses necessary for the treatment of the consequences of an accident provides for reimbursement of expenses for hospitalization, outpatient treatment, medicines, care.
As an option, payment of expenses for prosthetics, cosmetic surgery and spa treatment may be offered. The amount of guarantees is determined as a percentage of the costs incurred. For basic guarantees, the payment can be set at the level of 100% of payment for medical expenses, for additional guarantees no more than 20-50%. Usually the amount of this guarantee depends on the extent to which the costs of treatment are covered by social insurance or social security.
Speaking in general about insurance coverage for accident insurance, it is necessary to distinguish two different approaches to determining specific amounts of insurance payments. The insurance company sets the amount of all guarantees as a percentage of one amount provided for in case of death, or uses different sums insured to determine each guarantee. Domestic insurers prefer to calculate all guarantees based on one sum insured in case of death, using different percentages. However, in any case total amount payments of insurance indemnity for one or more insured events that occurred during the period of validity of the insurance contract cannot exceed the sum insured specified in the contract, or the sums insured for each guarantee, if the contract specifies several sums insured.
The model rules for accident insurance, developed by the All-Russian Union of Insurers, recommend determining the amount of insurance payment as a percentage of the sum insured for this type of insured event in accordance with the table of insurance payments when the insured person pays the general working capacity as a result of an accident based on a certificate from a medical institution , as a rule, without examination of the insured person (tab. 3). If the insured person has received damage to soft tissues, organs of vision, hearing or the genitourinary system, he may be referred by the insurer for examination to a specialist doctor to determine the consequences of such damage. According to the same Rules, in connection with the onset of temporary disability, it is made in the amount of 0.2% of the sum insured for this type of insured event for each day of disability, starting from the 6th calendar day of disability, but not more than 90 days per year.
Table 2. Excerpts from the table of payments in case of loss of general working capacity by the insured person as a result of an accident, % of the sum insured
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The nature of the damage or its consequences |
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Concussion requiring treatment for 10 days or more |
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brain contusion |
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Paralysis of accommodation in one eye |
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Injury to one eye resulting in complete loss of vision in one eye |
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Injury to one or both eyes resulting in complete loss of vision |
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Complete deafness |
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Rupture of the tympanic membrane as a result of trauma, without hearing loss |
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Lung injury resulting in: |
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pulmonary insufficiency |
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removal of part, lobe of lung |
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lung removal |
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Fracture of the sternum |
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Rib fracture: |
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three ribs |
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each next edge |
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Jaw fractures: |
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upper jaw, zygomatic bones |
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lower jaw, dislocation of the lower jaw |
2. Types of accident insurance
2.1 Compulsory accident insurance in Russia
Compulsory accident insurance is one of the elements of the social insurance system and covers the risks of industrial injuries and occupational diseases. Its scope is limited to the consequences of accidents occurring at the workplace or during working hours (including travel time to and from work). An essential feature of this type of insurance is that the insurance premiums are fully paid by the employer. In Russia, compulsory accident insurance is regulated by the Law “On Compulsory Social Insurance against Occupational Accidents and Occupational Diseases” of July 24, 1998 No. 125-FZ (as amended on July 17, 1999) and by-laws to it.
Another direction in the organization of compulsory insurance against accidents, supplementing or compensating social insurance, is compulsory state insurance life and health of those categories of civil servants whose professional activities are associated with an increased risk of an accident in the performance of their official duties. These include: judges, prosecutors, employees of the Ministry of Taxes and Duties, military personnel. State personal insurance covers risks identical to compulsory accident insurance: death and disability of the insured as a result of injury, injury, bodily injury that occurred in the performance of official duties. Compulsory insurance for civil servants is regulated by federal law. The third direction of compulsory insurance against accidents is the compulsory personal insurance of passengers transported by air, rail, water and motor transport on intercity and tourist routes.
Insurance against accidents at work and occupational diseases
Mandatory accident insurance is one of the elements of social insurance and covers the risks of industrial injuries and occupational diseases. An essential feature of this type of compulsory accident insurance is that the insurance premiums are fully paid by the employer. Compulsory insurance against accidents at work is usually subject to all employees, students, children attending preschool institutions, farmers and persons working in peasant farms.
Mandatory insurance against accidents at work and occupational diseases provides for the provision of social protection for employees through:
Compensation for harm caused to the life and health of employees in the performance of their duties employment contract or in other cases established by law;
Increasing the interest of enterprises and organizations in reducing the level of occupational risk;
Financing preventive measures to reduce industrial injuries and occupational diseases.
Funds received for accident insurance can be used by the FSS for the needs of state social insurance as a whole, which is confirmed by federal laws on the budget of the fund. Insurance contributions for compulsory social insurance against industrial accidents and occupational diseases are paid by insurers directly to the FSS. All employers are insured:
Legal entities of any organizational and legal form in relation to employees hired under labor contracts (contracts);
Individuals hiring other individuals under an employment agreement (contract).
Insurers are required to register with the executive bodies of the FSS at their location. Insurance premium rates are annually approved by federal law for the next year. Insurance rates are established by the FSS on the basis of the Rules for classifying sectors of the economy as a class of occupational risk. The amounts of insurance premiums are transferred by the insured on a monthly basis within the period established for receiving funds from banks for the payment of wages for the current month. Insureds who make the established insurance payments to the insured, who are in labor relations with them, the insurance premiums are transferred minus the payments made.
The object of compulsory insurance against accidents at work and occupational diseases are the property interests of individuals associated with the loss of their health, professional disability or their death due to an accident at work or occupational disease. The insured under this type of insurance are:
All individuals performing work on the basis of an employment contract concluded with the employer;
Individuals who have already received damage to health due to an accident at work or an occupational disease, confirmed in the prescribed manner, by the time of entry into force federal law on compulsory social insurance against accidents;
Individuals sentenced to imprisonment and involved in labor by the insured.
An insured event is a confirmed in the prescribed manner the fact of damage to health or death as a result of an accident at work or occupational disease. An accident at work is an event due to which the insured received damage to his health, which led to temporary or permanent loss of professional disability or death that occurred in the performance of duties under an employment contract both on the territory of the insured and outside it, while traveling to place of work or compensation from the place of work on transport provided by the policyholder (or on personal transport used for official purposes under an agreement or order of the employer). Accidents that occurred during the journey to the place of business trips and back, when working on a rotational expeditionary basis during between-shift rest, when an employee is involved in the elimination of the consequences of emergency situations, when performing actions that are not part of the employee's job duties, but committed in the interests of the employer (to prevent accidents, damage) are also considered as production.
Investigation and accounting of accidents at work is carried out in accordance with the regulation approved by the Decree of the Government of the Russian Federation of March 11, 1999 No. The employer is obliged to ensure the timely investigation and registration of an accident at work. The costs of investigating an accident are borne by the employer. The loss of professional disability of the insured is established by the institutions (bureau) of medical and social expertise on the basis of the request of the employer, the insurer or the independent request of the victim when submitting an act of an accident at work.
The date of appointment of insurance payments is the day of establishing the fact of loss of professional incapacity by the insured person. In the event of the onset of an occupational disease, the date of infliction of harm is either the date of detection of an occupational disease or the date of drawing up an act of investigation of an occupational disease, if it is not possible to determine the moment of the disease. When investigating an insured event, the commission may establish the fault of the insured in the occurrence of an insured event - gross negligence that contributed to the occurrence or increase of the damage caused.
If, as a result of an insured event, the death of the insured occurs, then the following persons are entitled to receive certain insurance payments: content, subject to the following conditions:
Children until they reach the age of 18, and students over 18 until graduation from educational institutions full-time education, but not more than 23 years;
Women who have reached the age of 55, and men who have reached the age of 60 - for life;
Disabled people - for the period of disability; 2) the child of the deceased, born after his death; 3) one of the parents, spouse or other family member, regardless of ability to work, who does not work and is busy caring for the dependent children of the deceased, grandchildren, brothers and sisters who have not reached the medical and social conclusion in permanent care; 4) persons who were dependents of the deceased, who became disabled within 5 years from the date of his death.
In case of damage to the life, health and professional working capacity of employees, they themselves or their relatives are guaranteed:
Temporary Disability Allowance;
Insurance payments - one-time, - monthly;
Payment of additional expenses for:
additional medical care,
Extraneous care for the victims, - sanatorium treatment,
Prosthetics and provision with the necessary devices for work and at home,
Provision of special vehicles and their content
Vocational training and retraining.
State life and health insurance for certain categories of civil servants
Another direction in the organization of compulsory accident insurance, supplementing or compensating social insurance, is compulsory state life and health insurance for those categories of civil servants whose professional activities are associated with an increased risk of accidents in the performance of their official duties.
Compulsory state insurance in the Russian Federation is subject to military personnel, employees of the Ministry of Internal Affairs, tax inspections, the state fire service, prosecutors, investigators, judges and people's assessors, rescuers, deputies of the Legislative Assembly, workers of nuclear facilities, astronauts, health workers who provide diagnostics and treatment of HIV infection, donors and some others.
Initially, Rosgosstrakh was engaged in state personal insurance. However, since 1993 there has been a clear trend of insurers moving to other, commercial insurance companies, mainly captive-type companies, the founders of which are the insurers themselves - the relevant ministries and departments are obliged to insure their employees. In order to carry out compulsory state personal insurance, an insurance company must have a license to carry out the corresponding type of insurance.
Recently, the issue of creating a state insurance company in the form of a state unitary enterprise in order to ensure compulsory personal insurance has been discussed. This is due to the fact that compulsory state insurance of life and health of civil servants is carried out at the expense of state budget and much of that money goes to commercial insurance companies.
State personal insurance covers risks identical to compulsory social insurance against accidents: injuries, bodily injuries that occurred in the performance of official duties. Insurance compensation is determined based on the official salary or minimum size wages.
Passenger personal insurance
The third direction of compulsory insurance against accidents is the compulsory personal insurance of passengers transported by air, rail, water and road transport on intercity and tourist routes. The insurance covers the risk of death or injury and bodily harm resulting from a travel-related accident.
The maximum sum insured to be paid in the event of the death of a passenger is established by law in the amount of 120 minimum wages as of the date of purchase of the travel document. In the event of an injury or injury, the amount of insurance compensation is calculated in proportion to the severity of the bodily injuries received as a result of the accident.
The insurers are the passengers themselves, who pay the insurance premium for compulsory personal insurance when buying a ticket. However, the interests of the policyholders in the execution of this insurance operation were represented by the transport organization-carrier, which chooses insurance company and concludes with it an agreement on the implementation of this type of insurance. The only requirement for an insurance company is to have an appropriate license to carry out compulsory insurance of passengers. Passengers without, having the right to free travel, are recognized as insured without paying an insurance premium.
Tariffs for compulsory personal insurance of passengers are approved by Rosstrakhnadzor and agreed with the ministries of transport and communications of the Russian Federation. The main part of the tariff is deductions to the preventive measures fund, the funds of which are sent to the institutions of these ministries to improve transportation safety (Table 1)
Table 3. Structure of the tariff for compulsory personal insurance of passengers of railway and intercity motor transport
Mandatory personal insurance of passengers in the form in which it is carried out causes a lot of criticism. First, the deduction of more than 90% of the insurance rate to finance the carrier's expenses makes compulsory passenger insurance more similar to additional taxation of the population. Secondly, transferring the responsibility of the carrier for the life and health of the passenger to the passenger himself is a measure unworthy of a civilized society. In many countries, this issue has been resolved by introducing the institution of compulsory material liability of the carrier for the life and health of passengers, and in some cases, compulsory liability insurance of the carrier. The current practice of compulsory passenger insurance in Russia is contrary to its civil law. In paragraph 2 of Art. 935 ch. 48 of the Civil Code of the Russian Federation states that the obligation to insure one's life or health cannot be assigned to a citizen by law. In the interests of consumer protection, it would be legitimate to establish the responsibility of the carrier for the life and health of passengers.
2.2 Voluntary accident insurance
Voluntary insurance is carried out on the basis of an insurance contract and insurance rules that determine general terms and Conditions and the procedure for its implementation.
The insurance rules are adopted and approved by the insurer or an association of insurers independently in accordance with the Civil Code of the Russian Federation and this Law and contain provisions on subjects of insurance, on objects of insurance, on insured events, on insurance risks, on the procedure for determining the sum insured, insurance rate, insurance premium (insurance premiums), on the procedure for concluding, executing and terminating insurance contracts, on the rights and obligations of the parties, on determining the amount of loss or damage, on the procedure for determining insurance payment, on cases of refusal of insurance payment and other provisions.
Voluntary accident insurance has several organizational forms. First of all, a distinction is made between individual and collective accident insurance.
An individual insurance contract is concluded by an individual, and the effect of the contract mainly applies to the insured and his family members.
Under a collective insurance contract, the insured is entity, and the insured - individuals in whose life and health the insured has a material interest.
Collective accident insurance
Collective insurance contracts are concluded either by employers in favor of their employees, or by various associations and societies in favor of their members. Collective insurance premiums are much more needed than individual insurance premiums, since there is an additional equalization of risk within a certain group.
AT Russian Federation collective accident insurance has its own specifics due to the peculiarities of the previously existing tax legislation, which allowed this form to be used to evade income tax, income tax and contributions to off-budget funds social value. Businesses used accident insurance to provide employees with additional cash benefits, bypassing mandatory deductions and taxes from the payroll established by law. This situation was possible due to the legal existence of insurance with the return of insurance premiums and preferential taxation of insurance premiums and insurance payments.
Currently, accident insurance has a less favorable taxation regime for insurance premiums and payments. Due to the tightening of the rules for taxation of insurance premiums, this type of insurance has become less attractive for use in order to provide "hidden" wages.
Individual accident insurance
Individual voluntary accident insurance exists in the following forms:
Full accident insurance, providing an insurance guarantee for any period of both private and professional life of a person during the term of the contract;
Partial insurance, which provides a guarantee only for a certain period of human life; the most common is accident insurance for the duration of a trip, travel, including abroad;
Additional insurance, i.e. the use of accident insurance as part of various combination or package policies; a guarantee of payment of a double sum insured in the event of death as a result of an accident in life insurance; accident guarantee in the package policy of the head of the family, etc. Accident insurance is the most common addition to many insurance policies and the most profitable risk for insurers within personal insurance.
3. Insurance rates
Insurance tariffs for accident insurance are determined according to the methods used in the construction of tariffs for risky types of insurance. Accident insurance refers to damage insurance, so the pricing is based on the principle of distribution of the insured risk among all insured. The calculation of the net accident insurance rate includes average unprofitability of the sum insured for this type of insurance.
Accident insurance rates generally depend on the gender and age of the insured. Insurance rates increase with an increase in the amount of the sum insured and the danger of the activities carried out by the insured, primarily professional. Insurance rates increase with an increase in the sum insured and the degree of riskiness of the professional and social obligations of the insured. Insurers use their own scales for matching tariffs and sums insured, as well as grouping professions depending on the potential danger.
The model rules for voluntary insurance of citizens against accidents contain the following recommendations for determining the sum insured and insurance premiums and the conditions for their payment. The sum insured is determined by agreement between the insured and the insurer for each type of insured event separately and may be different or the same for the selected types of insured events. If the policyholder enters into an insurance contract for several persons, then the contract shall indicate the total insurance amount for all insured persons and for each type of insured event. If the individual sums insured are equal, the total sum insured is determined by multiplying the sum insured established for one insured person by the number of persons named in the contract. If the individual sums insured are different, then the total sum insured under the contract is determined by adding the sums insured for each insured person.
Basic insurance rates are developed by the insurer independently. In special cases, when determining the size of the insurance premium, the insurer has the right to establish increasing and decreasing coefficients to the basic insurance rates, determined depending on the individual characteristics of the risk. The insurance premium under insurance contracts concluded for a period not exceeding one year is paid as a lump sum. When concluding a contract for a longer period, it is possible to pay the premium in installments, in two terms, and the first insurance premium must be at least 50% of the entire insurance premium. The second part of the insurance premium must be paid no later than half of the term of the contract. The insurance rate is set as an annual rate. When insured for a period of less than a month insurance premium paid at a rate of 0.7% annual rate for each day of validity of the insurance contract.
The insurance premium can be paid in different ways:
By bank transfer to the insurer's settlement account within five banking days from the date of signing the insurance contract, unless otherwise stipulated in the insurance contract;
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