The figure on the right shows the principal participants in the process of processing and settling cases of occupational accidents or diseases.
The employee informs the employer of the claim event, and the employer then notifies the insurance company. This notification institutes the claim.
The injured person or the care provider can also institute the claim by submitting a written notification to the insurance company. The notification must specify the name and contact details of the employer, details of the claim event and the injured person’s name, date of birth or personal identity code and contact information. In addition to these, the care provider must submit the patient records for the treatment appointment.
The insurance company informs the injured person of the claim having been instituted. The insurance company must also ensure that all the documents necessary for making a decision on the claim are at its disposal as soon as possible.
The insurance company must on its own initiative pay to the injured person the compensation laid down in the Workers’ Compensation Act to which he or she is entitled, subject to the legislation and the reports received.
The Act contains specifics provisions on the injured person having to apply for compensation within one year after the costs were incurred. These include:
- medications and treatment supplies
- additional housekeeping costs
- items broken during the claim event
- compensation for pay for the period of examination
- compensation for pay for a period of physiotherapy
In accordance with the Administrative Procedure Act, before the matter is decided, a party shall be given an opportunity to express an opinion on the matter and to submit an explanation on the demands and information which may have an effect on its decision. The purpose of the hearing is to facilitate the processing of the claim by providing the injured employee with an opportunity to express his or her opinion on the matter.
The injured person must be heard concerning the matter and the information which may influence the decision insofar as he or she has not been appropriately consulted when the information was sought. The hearing may be waived only if the accepted claim does not concern the other party or if the hearing is clearly irrelevant for other reasons.
The employer participates in the claim processing by submitting a notification of the claim event to the insurance company. Depending on the claim, the employer may be asked for other information during the processing, such as details of the employment relationship, earnings or rehabilitation.
Statement by the Accident Insurance Compensation Board
In certain cases, before a decision is made on a claim, the insurance company must request a statement from the Accident Insurance Compensation Board on its proposed decision.
Time limit for issuing decisions
The insurance institution must issue the decision on the claim promptly, and no later than 30 days from the date when it has received adequate information to resolve the matter.
If the time limit is exceeded, the insurance company will pay an increase for delay.
If the insurance company has not initiated the claim processing or issued the decision within the time limit, the injured person can apply to TVK for the delayed claim to be transferred to, and processed by, TVK. The request can be made with a free-form application to TVK in writing.
Format, content and grounds of the decision
The decision is issued in writing and must clearly indicated the following information:
- the authority that made the decision and the time of the decision;
- parties directly affected by the decision;
- grounds for the decision and itemised information on the rights and obligations of the parties or how another resolution has been reached;
- name and contact details of the person who can provide further information on the decision.
Grounds for the decision must be provided. If a decision is made to refuse compensation essentially on medical grounds, the grounds for the decision must indicate the factors that mainly influenced the assessment and the conclusions drawn on the basis of these.
A person who is dissatisfied with the decision issued by the insurance company can appeal to the Employment Accidents Appeal Board. Appeals against the Board’s decisions can be lodged with the Insurance Court. In some cases, appeals against the Insurance Court’s decisions can be lodged with the Supreme Court. Any decision will always include instructions on appeal.
The appeal is always submitted to the insurance company that made the decision. The insurer will first consider amending the decision on the basis of any new information obtained. If the decision is not amended, the appeal is submitted to the Appeal Board.
The appeal must be made in writing. The injured person does not have to seek legal advice for the appeal, and can lodge the appeal by a free-form letter. The appeal must be submitted within 30 days from the date when the party was informed of the decision.
The Employment Accidents Appeal Board processes the appeals free of charge. A court fee may be charged for the proceedings in the Insurance Court and the Supreme Court in accordance with the Court Fee Act (tuomioistuinmaksulaki 1455/2015).