Who is concerned
An insured person is deemed to be diagnosed with an occupational disease if they suffer from an illness:
- directly linked to exposure to a risk factor, or;
- due to hazardous working conditions.
For an employee to be recognized as suffering from an occupational disease, he must suffer from a condition caused directly:
- by more or less prolonged exposure to a physical, chemical or biological hazard, or;
- during the usual practice of the profession, or;
- by working conditions.
The insured person or the beneficiary must submit an application for recognition of an occupational disease within one year.
This period starts on the day on which the insured or beneficiary becomes aware of the occupational origin of the disease.
After the expiry of this one year period, the application is admissible only if the person concerned:
- proves that the consequences of the illness, in terms of the victim's working capacity, could only be ascertained later;
- was physically unable to make a request.
How to proceed
Declaring an occupational disease
The insured must have the medical declaration form for occupational diseases filled by their attending physician when the latter considers that an disease is directly linked to the professional activity.
The doctor fills out the form and sends it to the Accident Insurance Association (Association d'assurances accident - AAA).
The medical declaration must indicate:
- a precise medical diagnosis stating the professional activity as being the main cause;
- where appropriate, the number of the disease as defined in the table of occupational diseases;
- an indication of the professional risks which are likely to have caused the disease;
- medical documentary evidence confirming the declared disease.
The physician gives a copy of the medical declaration to the patient.
After receiving the medical declaration, the AAA sends an employer's declaration to the employer to obtain more information regarding the insured's professional activity.
Where necessary, any further medical or technical information will be added to the declaration by either:
- the attending physician, or;
- an expert, or;
- the employer who is required to provide all information regarding the risk exposure.
The AAA then checks the insured's career path. Depending on the medical complexity of the case, a medical expertise and technical investigations may be conducted. The AAA can request any additional document they deem necessary.
If the insured or their doctor suspects exposure to asbestos, the AAA will provide them with a specific questionnaire.
Once the file is complete, the AAA analyzes the file together with the Social Security Medical Board to decide whether it will cover the occupational disease or not.
If the insured's disease is recognized as being of professional origin, the AAA informs them by postal mail.
In case of a refusal of coverage, the AAA issues a motivated presidential decision to the insured.
Proving that the disease is occupation-related
The insured must respect 2 levels of evidence.
First, the insured who claims to be the victim of an occupational disease must prove that he has been exposed to a specific risk that may be the cause of the disease.
Secondly, if the insured proves this connection, it is necessary to distinguish between diseases listed on the occupational diseases table and those that are not.
If the disease is listed in the table of occupational diseases, the occupational origin of the disease is presumed to exist.
If the disease is not on the list of occupational diseases, the insured must prove:
- the existence of the occupational risk;
- the causal link between occupational risk and disease.
Proving the simple possibility of cause and effect is insufficient. The insured must prove a probability approaching certainty.
The recognition of certain diseases listed in the table of occupational diseases is subject to additional legal conditions (for example: the cessation of the professional activity causing the disease).
Benefits that can be claimed due to occupational diseases
Any insured person may claim the following benefits if the occupational disease is covered by the Accident Insurance Association:
- coverage of:
- benefits in kind, consisting of payment for health care related to occupational disease;
- benefits in cash in the event of total work incapacity, for the first 52 weeks, corresponding to the payment of the insured party's salary and other benefits during the period of incapacity for work;
- payment of a:
- full pension in the event of total work incapacity, if the insured is not entitled to the sickness benefit, or if the entitlement to the sickness benefit has expired;
- partial pension in the event of partial work incapacity with loss of salary;
- waiting pension in the event of professional retraining;
- compensation for non-patrimonial damages.
If the insured dies as a result of a recognized occupational disease, rightful claimants may apply for the following benefits:
Interested parties have several means of appeal at their disposal to assert their rights.