Social insurance for occupational risks in France

Who is covered?

The French Social Security Code states that “any individual in salaried employment, or working in any capacity or location for one or several employers or business owners”, is entitled to occupational accident/occupational disease insurance, from the moment they are hired.
 

Insurance schemes other than the general scheme:

• Farmers are required to have insurance. Agricultural workers are covered by the Mutualité sociale agricole, charged with the exclusive handling of occupational risks in agriculture. The insurance and compensation procedures are very similar to those of the general scheme.
• Self-employed professionals (business owners, tradespeople, manufacturers, and those in the liberal professions) are not covered for occupational risks, unless they pay into optional, individual insurance against workplace accidents and occupational diseases.
• Civil servant are covered by different schemes depending on the government service they work for. If they experience health problems related to their job, they must contact the relevant authority.
   

Specific social security provisions apply to certain activity sectors, but the general scheme covers some or all risks for specific groups (such as non-tenured state employees, utility workers, and support staff at the SNCF, the national rail company).

Who finances the occupational risk insurance under the general scheme?

The occupational risk insurance system is financed by mandatory insurance payments made by the two million establishments in the industrial, commercial and service sectors. Contribution rates are set by an occupational risk committee of the social security system. They are set according to the size of the establishment, the activity sector and the frequency and seriousness of accidents of which its employees may be victim. A contribution rate is set for each establishment, based on the annual wage bill, and is paid entirely by the employer.

Three rates are charged depending on the size of the enterprise (general rate, non-construction rate and the Alsace-Moselle region rate):

• Collective rate: between 1 and 19 employees
• Blended rate: between 20 and 149 employees
• Individual rate: over 150 employees

Recognition and compensation

The occupational accidents and diseases  branch of Social Security only provides compensation for bodily harm and loss of income caused by accident or disease to employees covered by the general scheme of the social security system. CPAM (the ‘primary health insurance fund’) processes all claims regarding occupational accidents and diseases. When the accident or disease is recognised as occupational in nature, the employee’s health care costs are fully covered and they receive various forms of financial compensation based on their situation (daily allowance, capital, pension).

Occupational accidents

According to Article L.411-11 of the social security code, “shall be considered an occupational accident, regardless of its cause, any accident which occurs as a result of, or during work, to any employee or person working in any capacity or location, for one or several employers or business owners”.
Three conditions must be met for an incident to be classified as an occupational  accident: an unusual occurrence causing an immediate or delayed injury; the occurrence of the accident during, or as a result of, work; and a link between the sustained injury and the declared accident.
Any accident which occurs during work, in the workplace, is presumed to be an “occupational accident”.

Commuting accidents  

According to Article L. 411-22 of the social security code, “shall also be considered an occupational accident, when the victim or their beneficiaries provide proof that all of the following conditions have been met, or when an investigation provides the insurance entity with sufficient evidence, any accident suffered by an employee specified by this code, during the journey to or from work, between:

• their primary place of residence, a stable secondary place of residence, or any other location the employee goes to habitually for reasons linked to family and his place of work. The journey may be longer than the most direct route if the detour taken is necessary for the purposes of a recurrent car-pooling activity;
• the place of work and the restaurant, cafeteria, or more generally the location where the employee usually eats their meals, to the extent that the journey is not interrupted or used for a reason guided by personal motives unrelated to the essential daily needs or to work.”

Occupational diseases

A disease is considered work-related if it is the direct result of an employee’s regular exposure to a physical, chemical or biological risk or the result of the conditions in which he performs his professional activity.

An occupational disease is the result of more or less prolonged exposure to a risk which is present during the usual execution of a job. This may involve inhaling small doses of toxic dust or vapours on a daily basis, or repeated exposure to physical elements (noise, vibrations, etc.). It is almost always impossible to determine the exact moment at which a disease begins; certain occupational diseases only become apparent years after exposure to the risk began, and sometimes a long time after the employee has stopped performing the incriminated job.

The work-related cause of the disease is rarely obvious; sometimes it is quite difficult, given the many harmful substances and situations to which an employee is exposed, to identify the cause(s) of trouble. In this case, data concerning the location, date and the cause-and-effect connection are often hard to pinpoint and the ‘physicality’ of an occupational disease generally cannot be established by proof that is never easy, if not impossible, to provide. Therefore, in a large number of claims, the right to compensation is based on medical and technical probability criteria and on administrative ‘presumption’ criteria.

To be considered occupational in nature and lead to compensation, a disease must:

• appear on one of the occupational disease tables (French database). These tables are created and updated by decree to reflect changes in techniques and progress in medical knowledge.
  Any condition which meets the medical, occupational and administrative conditions stated in the tables is systematically “presumed” to be occupational in nature, without an obligation to provide proof.
• be identified as directly linked to the professional activity by the complementary recognition system for occupational diseases (it is possible to establish the occupational nature of a disease leading to death or at least 25% permanent incapacity, even if this disease does not meet all of the medical and legal conditions stated in the tables or is not included in one of the tables). For an “off-table” disease to be recognised, the victim cannot rely on a presumption of its origin; a direct link must be established between the disease and the work. The employee’s claim is submitted to the regional occupational disease recognition committee (C2RMP), which issues a reasoned opinion on the existence of a direct link between the professional activity and the disease. INRS is not directly involved in the recognition process for occupational diseases but is sometimes asked to act as an expert before the C2RMP.