LAA vs LAMal: who pays what in the event of an employee accident in Switzerland?

An accident involving an employee triggers the same chain of questions in all SMEs: who should be notified, to whom, and which insurer will pay for medical care and loss of earnings? When the answer is unclear, the case drags on: overlapping invoices, delays, discussions about "accident or illness", and sometimes expenses borne by the employee when the case should have been covered by the LAA (Accident Insurance Act).

Reading promise: by the end, you will be able to decide between "LAA or LAMal" with a simple grid, document the decision, and set up a follow-up that works for management, finance and HR.

LAA vs LAMal: understanding the logic before discussing claims

What the LAA covers from the employer's perspective (AAP and AANP)

Accident insurance (LAA) is mandatory for employees in Switzerland. Employers insure their employees against accidents and occupational illnesses. If a person works at least 8 hours per week for the same employer, they are also insured against non-occupational accidents (leisure activities).

In an SME, this translates into two coverage areas to manage:

• AAP (occupational accidents): for all employees.

• AANP (non-occupational accidents): only if the threshold of 8 hours per week is reached with the same employer.

On the financing side, remember the "decision and traceability" angle: AAP bonuses are the responsibility of the employer, AANP bonuses are in principle the responsibility of the employee (even if the employer pays all the bonuses and then makes the salary deductions according to the planned model).

What LAMal covers (and when it becomes the accident payer)

Health insurance (LAMal) is a safety net for medical treatments. It also provides coverage in the event of an accident when no accident insurance covers the case.

Key point: an employee fully covered for accident risk under the LAA (occupational and non-occupational accidents) can request their health insurance provider to suspend accident coverage under their basic insurance. The suspension takes effect no earlier than the first day of the month following the request.

Conversely, if the person is not insured under LAA for non-occupational accidents (for example because they work less than 8 hours per week), they must retain accident coverage in their LAMal.

Who pays for what? A five-question decision tree

The goal is to decide quickly, and then be able to explain and prove the decision. Here is a robust framework.

Question 1: Are we talking about an accident in the sense of social insurance?

The reference definition (art. 4 LPGA) describes an accident as a harmful, sudden and involuntary event, due to an extraordinary external cause, which compromises health or results in death.

In practice, if an element is missing, the event may be reclassified as an illness, resulting in a change in the rules governing coverage. This is one of the frequent reasons for denials by accident insurance companies.

Question 2: Was the person insured under the LAA at the time of the events?

LAA coverage begins from the start of the employment relationship (or the right to salary), and at the latest as soon as the person starts their journey to work.

Question 3: Has the 8-hour threshold been reached or not?

• At least 8 hours per week with the same employer: AAP + AANP coverage. [1][3]

• Less than 8 hours per week: no AANP coverage; the person must be covered for leisure accidents via their LAMal.

An exception to be aware of and document: for a person with a commute of less than 8 hours, accidents on the shortest home-work journey are covered under the AAP.

Question 4: Where did the accident take place (work, commuting, leisure)?

Useful reference points:

• Workplace accident: during an activity carried out on the employer's orders or in their interest; and also, in certain situations, during breaks, before or after work if the person is legitimately present at the workplace or in the danger zone related to the activity.

• Non-occupational accident: anything that does not fall under the category of "occupational", for people covered by AANP.

Question 5: Is the coverage still active (end of contract, break, unemployment)?

Accident insurance does not end immediately upon the termination of the contract. It ceases at the end of the 31st day following the end of the entitlement to at least half-salary. To avoid a gap in coverage, the supplementary insurance can extend coverage for non-occupational accidents for up to 6 months.

Quick reference table (without special cases)

Situation	Primary payer	Pilot decision
Accident occurring during work or in the employer's interest	LAA (AAP)	Report to the employer's accident insurer.
Accident on the way to work, employee working at least 8 hours/week	LAA (AANP)	Define the route and open the LAA file.
Accident on the commute, employee working less than 8 hours/week	LAA (AAP, journey exception)	Check the "less than 8 hours" status and document the route.
Leisure accident, employee working at least 8 hours/week	LAA (AANP)	Confirm AANP coverage.
Leisure accident, employee working less than 8 hours/week	LAMal (including accidents)	Ensure that accident coverage is not suspended under LAMal.
Accident after the end of LAA coverage, without extension	LAMal (if accident included)	Anticipate the transition (insurance by agreement or reactivation of LAMal).

These benchmarks are based on: the 8-hour threshold, the exception for journeys of less than 8 hours, and the start/end rules for coverage.

Mini case study 1: Fall on the premises, work stoppage

Situation: an employee is injured on the company's stairs during his workday.

Decision: case to be reported to the employer's accident insurance (AAP).

To be documented: facts, witnesses if useful, medical certificate, dates of incapacity and return to work.

Mini case study 2: Part-time employee, accident on the way home

Situation: An employee works less than 8 hours per week. She falls on the most direct route between home and work.

Decision: Commuting accidents are covered by the AAP (exception). Leisure accidents remain outside the AANP, therefore accident coverage must remain active under LAMal.

Services and costs: what the difference really changes

Medical care: cost sharing or not

In LAA, the accident insurer covers the treatment costs and, unlike health insurance, there is no deductible or co-payment to be borne by the insured.

Under LAMal, if the health insurer is the accident payer, benefits are subject to cost participation: a 10% co-payment (beyond the deductible) and a contribution of 15 francs per day in case of hospital stay, according to LAMal rules.

For a manager or CFO, the consequence is very concrete: properly directing the case reduces internal friction and avoids subsequent discussions about costs that could have been avoided.

Loss of earnings: the LAA includes a daily allowance

In the event of incapacity for work following an accident, the LAA provides for a daily allowance paid for each day starting from the third day following the day of the accident. In the event of total incapacity, this allowance corresponds to 80% of the insured earnings.

Under the Swiss Federal Law on Health Insurance (LAMal), mandatory health insurance is not intended to replace income. There is optional daily allowance insurance (separate from other insurances) which can cover temporary wage losses in case of incapacity for work, but this is not automatic and is managed as a coverage decision.

Box: What needs to be documented

• Weekly hours at your home (reference 8 hours) and start date of the work report.

• Contact details and scope of your accident insurer (AAP/AANP).

• If the person is less than 8 hours away: check that accident coverage is not suspended under LAMal.

• Factual description: date, time, place, activity, circumstances, witnesses if relevant.

• For a journey: usual route, reason, and consistency with "most direct route" if applicable.

• Medical certificates, dates of incapacity and return to work.

• Elements needed to calculate the loss of earnings (to be transmitted in a proportionate manner).

• Log of exchanges and decisions (who, when, what).

Guidelines and checklists for executives, CFOs and HR

Piloting: Mapping your risk zones

A small or medium-sized enterprise (SME) saves time when it knows where the confusion is repeated:

• Part-time work below the 8-hour threshold.

• Timetable variations (passing above or below the threshold).

• Commuting accidents.

• End of contract and transitions (31-day notice period, possible extension).

Documenting: formalizing an internal rule "one page"

Objective: to make the decision reproducible.

• Qualification rule: accident or illness, occupational or non-occupational, 8-hour threshold.

• Transition rule: end of contract, 31-day notice period, option to extend.

• "Part-time" rule: no LAMal accident suspension if the person does not have the AANP.

Follow-up: Treat the accident as a process

• Pilot: open the file, qualify, announce.

• Document: collect the minimum pieces of evidence, trace the decisions.

• Follow up: track incapacity for work, returns to work, and payroll/billing consistency.

Common mistakes and how to avoid them

1. Suspend LAMal accident coverage for part-time work of less than 8 hours

Risk: gap in coverage for leisure accidents.

Parade: systematic threshold check before any suspension.

2. Mischaracterizing a commuting accident

Risk: referral to the wrong regime (AAP vs AANP) according to the threshold.

Parade: document weekly hours and itinerary from the moment the file is opened.

3. Forget about the end of coverage and the 31-day deadline

Risk: accident after the end of LAA coverage, without relay.

Parade: HR offboarding with reminder of options (extension by agreement or LAMal reactivation).

4. Under-documenting the facts

Risk: reclassification of accident vs. illness, and back-and-forth between insurers.

Parade: standardize immediate factual collection.

5. Minimize the impact of "cost sharing"

Risk: deductible, co-payment or hospital contribution under LAMal when the case falls under LAA.

Solution: explain to the employee the chosen plan and why.

Questions to ask your insurer or broker

1. What is our exact AAP/AANP coverage (including for part-time employees)?

2. What documents and what timeframe do you recommend for an accident report?

3. How do you classify commuting accidents according to the 8-hour threshold?

4. What are the typical causes of refusal or reclassification, and how can they be prevented?

5. How do we coordinate the daily allowance with our payroll and absence management?

6. What procedure do you recommend for contract terminations (31-day notice period, extension)?

7. What information should be given to employees regarding the suspension of LAMal accident insurance?

8. Which cases should be transferred to LAMal and how can double filings be avoided?

9. What monitoring indicators (delays, resumptions, recurrences) do you recommend?

10. Can you review our internal "one page" rule and confirm its consistency?

Conclusion

LAA vs LAMal is best managed when a stable framework is applied (8-hour threshold, work-related or non-work-related accidents, transition rules), when facts are documented, and when the case is monitored until recovery. A useful next step: audit your portfolio and claims processes to address sensitive issues (part-time work, commuting, outings).