Who is concerned
An insured person is deemed to be diagnosed with an occupational illness if they suffer from an illness:
- directly linked to the exposure to a risk factor; or
- due to hazardous working conditions.
For a salaried worker to be recognized as suffering from an occupational illness, they must suffer from a condition caused directly:
- by more or less prolonged exposure to a physical, chemical or biological hazard; or
- within the framework of the normal pursuit of a profession; or
- by working conditions.
The insured person or the beneficiary must submit an application for recognition of an occupational illness within one year.
This period starts on the day on which the insured or beneficiary becomes aware of the occupational origin of the illness.
After the expiry of this 1-year period, the claim is only receivable 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 file their request, due to reasons beyond their control.
How to proceed
Declaring an occupational illness
Insured persons must have their general practitioner complete a medical declaration of an occupational illness if said physician has determined that the illness is mainly caused by the occupational activity.
The physician fills out the form and sends it to the Accident Insurance Association (Association d'assurance accident - AAA).
The medical declaration must indicate:
- a precise medical diagnosis of the illness suspected to have its origin in the professional activity;
- the reference number of the illness as listed in the table of occupational illnesses (tableau des maladies professionnelles);
- an indication of occupational risk factors that are likely to be at the origin of the illness;
- medical documents establishing the declared illness.
The physician must give a copy of the medical declaration to the worker.
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 required will be added to the medical declaration by either:
- the attending physician; or
- experts; or
- the employer who is required to provide all information regarding the risk exposure.
The AAA will then check the insured person's professional background. Depending on the medical complexity of the case, a medical expertise and technical investigation may be conducted. The AAA can request any additional document they deem necessary.
If the insured person or their attending physician suspect an exposure to asbestos, the AAA will send them a specific questionnaire.
Once the file is complete, the AAA analyses the file together with the Social Security Medical Board in order to reach a decision on whether or not to cover the occupational illness.
If the insured person's illness is a recognised illness of occupational origin, the AAA will inform them by simple letter.
If the cover is denied, the AAA will issue a reasoned presidential decision (décision présidentielle) to the insured.
Proving the occupational origin of the illness
The insured must respect 2 levels of proof.
First, the insured person who claims to be the victim of an occupational illness must prove that he has been exposed to a specific risk that is deemed to be the determining cause of the illness.
Secondly, if the insured proves the connection, it is necessary to distinguish between illnesses listed in the table of occupational illnesses and those that are not.
If the illness is listed in the table of occupational illnesses, the occupational origin shall be presumed to exist.
If the illness is not listed in the table of occupational illnesses, the insured person must prove:
- the existence of the occupational risk;
- the causal link between occupational risk and illness.
Proving the simple possibility of a causal link is not enough. The insured must prove a probability approaching certainty.
The recognition of certain illnesses listed in the table of occupational diseases is subject to additional legal conditions (such as: the cessation of the professional activity causing the illness).
Benefits that can be claimed due to occupational illnesses
Any insured person may claim the following benefits if the occupational illness is covered by the Accident Insurance Association:
- coverage of:
- benefits in kind consisting in the coverage of the cost of healthcare attributed to an occupational illness;
- benefits in cash in the event of total incapacity for work, for the first 78 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 annuity in the event of total incapacity for work, provided the insured is not entitled to sickness benefits, or if the right to sickness benefits has expired;
- partial annuity in the event of partial incapacity for work with loss of salary;
- waiting-period allowance in the event of a job redeployment;
- compensation for non-patrimonial damages.
If the insured dies as a result of a recognized occupational illness, rightful claimants may apply for the following benefits: