In the event of everyday accidents, in the absence of a responsible third party, only part of your bodily injury will be covered by social organizations. Insurance policies exist to cover these damages. Here, for the most sold, their strengths and the pitfalls to avoid.
Eleven million people are victims of everyday accidents each year. Burning barbecue, electrocution, falling on a staircase or a sidewalk: the chances of getting injured are more numerous than we think. If the consequences of these accidents are, most often, benign (superficial cuts, bruises …), several tens of thousands of people have disabling consequences for life, and nearly 20,000 die each year … Four times more than on the roads
However, when you injure yourself alone, or if one of your relatives – spouse, children – is responsible for the accident, the financial consequences of your bodily injury will only be partially covered. Certainly, your medical expenses – hospitalization, surgical interventions, rehabilitation … – will be covered in part, or even in full, by health insurance and your complementary health if you have one. Likewise, if your accident resulted in a work stoppage, you may receive, within certain limits, daily allowances from your compulsory pension scheme to compensate for your loss of income. However, if you suffer from the consequences resulting in permanent incapacity, you can only claim a disability pension if your working or earning capacity is reduced by at least two thirds. In addition, this pension is reserved for active social insured persons – your unemployed spouse or your children cannot benefit from it – and will, in any case, be very largely insufficient to cover any costs linked to the assistance of a third person for life. However, for an annual fee of 100 to 300 €, depending on whether it is an individual or family contract, it is possible to take out insurance called “life accidents”, the purpose of which is precisely to cover the costs of assistance, as well as all the losses suffered, whether economic or personal (suffering endured …), even in the case of a weak handicap (most contracts only require a disability rate of 5 or 10%, see p. 72) and for a high amount (up to 2 million euros for some, even without ceiling at the Maif). To help you choose the right contract, we have carefully screened the 12 best-selling life insurance contracts in France: not all offer the same levels of guarantees, including the so-called Life Accident Guarantee contracts (GAV), however subject to a label (see opposite).
Only accidents due to an external cause are covered
These contracts cover accidents that have occurred in the context of your private life: at home, on the street, during a sporting or leisure activity, including during your holidays abroad, under certain conditions. By accident, we should understand any sudden, unforeseen event, individual or collective, due to an “external cause”. Which excludes health accidents: infarction, stroke …
However, bodily injury caused by a natural event, such as an avalanche or a storm – even if it is not a natural disaster recognized by ministerial decree – or by a technological accident, is covered. the explosion of a factory near your home. With a few exceptions, medical accidents resulting from a misdiagnosis or an awkward surgical intervention, as well as bodily injury suffered during an assault (assault and battery) or an attack, are also covered. . Admittedly, there are two specific guarantee funds – the National Office for Compensation for Medical Accidents (Oniam), and the Guarantee Fund for Victims of Terrorist Acts and Other Crimes (FGTI) – that can compensate you when you are the victim of a medical accident or an attack. However, their conditions of intervention are strict, and administrative – even judicial – procedures are often lengthy. Life accident insurance, and this is one of their major assets, is triggered immediately, before any search for liability.
Some establishments add accident categories to this list of guaranteed events, such as commuting accidents between home and the workplace (Groupama, Macif). BNP Paribas and Matmut also cover accidents at work, as does Maif (but not its subsidiary Filia Maif), which is reserved for certain professional categories, such as personnel from the French national education system. Crédit Agricole and LCL also, but only for artisans, merchants and liberal professions.
Please note: all these products guarantee accidents at school or in a sports club and, if they are of good quality, can be used as school or sports insurance. In addition, if you do not have a “driver's guarantee” with your car insurance (essential to be compensated for your bodily injury if you are responsible for a traffic accident), know that GMF and Macif also automatically included in their contract.
Certain benefits play out as soon as a covered accident occurs
As soon as you are the victim of a guaranteed accident, you benefit on the field from the “assistance” part of your contract, which is largely put forward by insurers. It is however only very rarely interesting. In general, the company is content to take care of the transfer of a loved one to your bedside, set up for a few days a home childcare service (or accompanied driving between your home and the school), finances 20 to 30 hours of domestic help and sometimes takes temporary care of your pets. In short, benefits that you already benefit from with your complementary health insurance. In the end, only Maif really stands out by covering the loss of income – up to € 15,000 – of a relative who came to help the insured immobilized at home for at least 3 months, and all the time necessary to his recovery. And, for the most seriously injured, by offering a “televigilance” service allowing emergency calls to be made by pressing the button on a bracelet.
Some contracts also provide for the reimbursement of healthcare costs (hospitalization, surgery and pharmacy) up to the amount not covered by Social Security and complementary health insurance. But, here again, all contracts are not created equal: GMF covers a maximum amount of € 4,000, Maaf increases to € 6,894 on condition of having a work stoppage of more than 30 days. The most generous is still the Maif, which reimburses 100% of the bill.
On the other hand, if the Postal Bank also provides for the reimbursement of healthcare costs, this guarantee does not systematically apply. These costs will only be reimbursed, up to a limit of € 50,000, if you maintain a handicap (or partial permanent incapacity) greater than 10%. Another risk that is sometimes immediately covered: temporary incapacity for work, that is, loss of income due to a work stoppage. The Maif and the Matmut make up part of the shortfall. A risk also covered by the Savings Bank (up to € 50,000), the Postal Bank (for € 25,000), Credit Agricole and LCL (up to € 15,000 maximum), but only if you keep after-effects of the accident, and provided that your rate of permanent incapacity is higher than the intervention threshold of the contract.
Most of the compensation is only paid from a certain handicap
The real interest of an insurance covering the daily accidents lies in the compensation to which you can claim in the event of handicap. An expert doctor, mandated by the insurer, will first determine the degree of severity once the period of care has ended and your state of health consolidated, that is to say when it is no longer likely to 'to evolve. Expressed as a percentage, on a scale of 0 to 100%, this rate of permanent disability, determined on the basis of a scale common to all insurers, measures the definitive loss of your physical, intellectual and sensory capacities (taste, smell …). For example, the loss of a finger corresponds to a rate of partial permanent disability (PPI) of between 6 and 8%; hearing loss in one ear at a PPI rate of 14%. Once this rate has been determined, you can only claim compensation if it is higher than the intervention threshold of your contract. So be sure to subscribe to the formula at the lowest threshold, most offering a level of 10%, some, it is even more advantageous, lowering this threshold to 5%, or even 1% only for the contract of the GMF.
The compensable damages are not the same from one contract to another
If the planned incapacity threshold is reached, these contracts then compensate the actual disability (prejudice to PPI), corresponding to the loss of physical or intellectual capacity. Most also guarantee the “professional incidence” linked to the handicap – loss of income if you are obliged to reclassify yourself or unable to work -, as well as the costs occasioned by the handicap – assistance costs. '' a third person, home improvement costs (widening of doors, access ramps, grab bars …) or of a car (swivel seat, accelerator circle on the steering wheel …). Certain contracts go further – in particular those labeled GAV (see p. 68) – and provide for compensation for your “personal” damage other than the handicap itself: compensation for the suffering endured, for the aesthetic damage (loss of a limb, scar on the face …) and pleasure (inability to practice a sport or a hobby). Finally, in the event of the death of the insured, the contracts cover the funeral costs (up to a limit of € 3,000 to 5,000, as the case may be), as well as the economic (and sometimes moral) damage suffered by his beneficiaries. law.
Favor compensation according to common law
It remains to be seen what the amount of your compensation will be. Certain insurers, essentially mutuals, offer compensation of a flat-rate type: for each type of damage covered by the contract, they very precisely predict what the disabled insured person (or his relatives in the event of death) will perceive based on multiple criteria. Thus, at Maif, a 45-year-old person who finds himself with a PPI rate of 25% (loss of vision in one eye, for example) will be entitled to € 40,040 for permanent disability (20 PPI points multiplied by € 2,002, sum corresponding to the value of the PPI point for a person of his age). At Matmut, in the event of aesthetic damage (this being assessed by an expert doctor on a severity scale of 0.5 to 7), the insured may claim compensation of € 5,000 for “average” damage estimated at 4. If these scales are sufficiently fine and generous, as is the case at Maif and Matmut (with option 5), the capital paid will be sufficient to repair the damage actually suffered. This is not the case with the BNP Paribas or Crédit Mutuel contract. For the latter, with a handicap evaluated at 60%, for example, you will be entitled in all and for all to € 83,200, whatever your age. A ridiculous sum for an active 30-year-old who needs home help the rest of his life.
You will not have any risk of under-compensation with contracts whose benefits are calculated according to the rules of ordinary law (see table p. 70). The amount paid will then theoretically be equivalent to that which you could have obtained in court against the person responsible for an accident. From a given incapacity rate, its amount takes into account its repercussions on your professional and family life taking into account your age, your profession, your income … For example, compensation can vary from 5,000 € for a sexagenarian who falls to the ground and partially loses the mobility of her knee … to more than 1.5 million euros for a young thirty-something executive who has become quadriplegic following a fall from a horse, and whose state will require continuous home help throughout his life.
Beware of compensation ceilings
The majority of contracts, including those for which the calculation method is governed by ordinary law, however include a compensation limit. Whatever the extent of your loss, the compensation can never exceed this limit. If you are under 40, or young children, it is better to favor a contract whose ceiling, all damages combined, is as high as possible. Concretely, a global guarantee level of € 800,000 is a minimum to be adequately protected, which excludes BNP Paribas and Crédit Mutuel contracts, as well as entry and mid-range formulas from Maaf, Macif and Matmut. On the other hand, you have a very serious chance of being fully covered, whatever your needs, with the contracts of the Postal Bank, Credit Agricole, LCL and Groupama, whose ceilings amount to 2 million 'euros. The Maif stands out once again, by not setting any ceiling.
The benefits paid by Social Security, provident organizations and employers always deduct the capital to which you can claim, whether the contract is of a lump sum type or governed by the rules of ordinary law, except for BNP Paribas and Credit Mutuel, with which accumulation is possible. In the event of a disability and with these two exceptions, the invalidity pension, if you are entitled to it, will be deducted from the compensation paid by the insurer. Similarly, in the event of the death of the insured person, any survivors' pensions or widowhood allowance will be deducted.
There is also no point in hoping to accumulate the indemnities of several life accident contracts, since insurance cannot be a source of enrichment for the insured. On the other hand, flat-rate benefits, such as the capital paid by death insurance which may be taken out elsewhere, can be added to the compensation of the insurer. And if a third party is responsible for your accident, the insurer reserves the right to take legal action to recover the compensation paid without there being any accumulation for you. Only possibility: if you consider that all your damages have not been taken into account by the insurer, and that the responsible third party is solvent or has a civil liability insurance, you can seek to obtain from him additional 'compensation.
Restrictions on place of accident and age
If you or your children make long stays abroad, be aware that most contracts do not cover accidents occurring outside French (or European) territory when the stay is more than 3 months. The Maif and the Matmut increase this duration to 12 months (as well as the Agricultural Credit and LCL for the children of insured persons educated abroad). Only BNP Paribas, Maaf and GMF exercise this guarantee without time restriction.
Age limits are also things to consider carefully. Except for GMF, Maif and Macif, it is impossible to subscribe after 65 years of age. An exclusion that starts even from age 60 at Matmut. Worse, at Maaf, the guarantees stop playing from the seventy-first birthday of the insured, while the Société Générale no longer pays a cent from 85 years old … Even if the benefits of your contract are said to be life , however, beware of its application conditions. For example, at Macif, the guarantee covering the risk of disability jumps from the age of 75. And if it remains valid at Matmut, the allowance is revised downwards by 4% per year from the age of 60 (with a maximum of – 20%). At Groupama, it's not much better: policyholders over 70 are only covered if their disability rate exceeds 30%, compared to 5% before this age. As for the initial compensation ceiling, which is rather comfortable (2 million euros), it is then reduced to 300,000 € … So many criteria relating to your personal situation, to look closely before subscribing, but which should not Do not forget that these contracts meet real needs poorly taken care of by social organizations.
The Life Accident Guarantee label only defines a minimum
Without being a criterion of excellence, the “Life Accident Guarantee” (GAV) label means that the contract complies with certain basic rules defined by the French Federation of Insurance Companies (FFSA), both in terms of concerns covered accidents, compensated damages and the method of compensation. Each insurer is free to customize its contract to go beyond this common minimum. GAVs represent 2.7 million contracts out of the 10 million insurance policies covering life accidents sold at the end of 2007.
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