Wachholz St
Versicherungsmedizin. 2015 Dec 1;67(4):184-9.
The insurance branch that covers the risk of occupational disability ranks among the most important private entities for offering security as far as the limitation or loss of one's ability to work is concerned. The financial risk of the insurer, the existential concerns and expectations of the claimant, as well as the legal framework and the need for a careful interdisciplinary evaluation, necessitate a professional review and assessment of the facts conducted with a sense of both responsibility and sensitivity. Carefully deliberated and sustainable decisions benefit both insurers and the insured. In order to achieve this, an opinion is required in many--and especially the more complex--cases from an external medical expert, which in turn can only be plausible and conclusive when based on a comprehensive review of the claimant's working environment and its particular (and often unique) requirements. This article is intended to increase the reader's understanding of the coherencies of workplace analysis and medical assessments, as required by insurance law and legislation. In addition, the article delivers valuable clues and guidance, both for medical experts and claims managers at insurance companies. Primarily, the claimant's occupation, as conceived in the terms and conditions of the insurance companies, is explained. The reader is then introduced to the various criteria to be considered when a claimant has several jobs at the same time, is self-employed, could be transferred to another job, is simply unable to commute to the workplace, or is prevented from working due to legal restrictions related to an illness. The article goes on to address the crucial aspect of how the degree of disability is to be measured under different circumstances, namely using the quantitative and the qualitative approach. As a reliable method for obtaining the essential data regarding the claimant's specific working conditions, which are required by both the medical expert and the insurance company's claims manager, the reader is provided with an insider's insights into on-site workplace analysis. The value of this pragmatic and proven method is subsequently demonstrated when the article addresses the often decisive part of the medical expert's assessment. In its conclusion the article points out the importance of workplace analysis to the entire process of evaluating occupational disability claims and the effort and monies to be saved by attaching value to thorough workplace analysis at an early stage.
就工作能力受限或丧失而言,承保职业残疾风险的保险部门是提供保障的最重要的私人实体之一。保险公司面临的财务风险、索赔人的生存担忧与期望,以及法律框架和细致的跨学科评估需求,都使得必须以负责且审慎的态度对事实进行专业审查和评估。经过深思熟虑且可持续的决策对保险公司和被保险人都有益。为实现这一点,在许多(尤其是较为复杂的)案例中需要外部医学专家提供意见,而这只有在全面审查索赔人的工作环境及其特殊(且往往独特)要求的基础上才可能合理且有说服力。本文旨在增进读者对保险法律和法规所要求的工作场所分析与医学评估之间连贯性的理解。此外,本文还为医学专家和保险公司的理赔经理提供了有价值的线索和指导。首先,解释了保险公司条款和条件中所界定的索赔人的职业。接着向读者介绍了在索赔人同时从事多项工作、为个体经营者、可转岗至另一工作、只是无法通勤到工作场所,或因与疾病相关的法律限制而无法工作时需要考虑的各种标准。文章进而探讨了在不同情况下如何衡量残疾程度这一关键问题,即采用定量和定性方法。作为获取医学专家和保险公司理赔经理都需要的有关索赔人具体工作条件的关键数据的可靠方法,本文为读者提供了对现场工作场所分析的内行见解。当文章论述医学专家评估中通常起决定性作用的部分时,展示了这种务实且经过验证的方法的价值。文章在结论中指出了工作场所分析对评估职业残疾索赔整个过程的重要性,以及在早期重视全面的工作场所分析所能节省的精力和资金。