LAA: What is a dental case, who intervenes? What coverage and exclusions are included?

Introduction

A dental case can cost time, energy, and sometimes trigger an unnecessary debate between accident insurance (LAA), health insurance (LAMal), and supplementary insurance providers. In SMEs, the risk isn't just financial: it's a governance risk. Who decides? Who files the claim? What documents are required? And at what point does a broken tooth actually constitute an accident in the legal sense?

In this article, you will be able to make decisions faster: understand what is called a dental case in LAA, identify typical coverages and exclusions (especially chewing accidents), and implement a “pilot, document, follow” method to reduce refusals and accelerate treatment.

1. LAA dental case: what exactly are we talking about?

1.1 “Dental case” is not a legal category, it is a type of claim

In practice, a "dental case" is defined as damage to a tooth, crown, bridge, or prosthesis, and insurance coverage is being considered. From an accident insurance perspective, the question isn't "dental or not," but rather: is it an accident as defined by law? Suva (the Swiss National Accident Insurance Fund) reiterates the legal definition of an accident (damage that is sudden, unintentional, and caused by an extraordinary external event).

1.2 The key: the concept of accident (LPGA) and the “extraordinary external factor”

Case law clarifies that the extraordinary nature of the event does not refer to the consequences (a broken tooth can be serious), but to the external factor itself. It is this point that determines whether a dental case qualifies for coverage under the LAA (Law on Accident Insurance)... or is rejected.

1.3 Why this is a sensitive issue in business

Dental incidents often occur outside the "typical" context (falls, impacts): sports, household accidents, or chewing food. Reporting procedures can vary (employee, HR, manager), and incomplete documentation increases delays. The best approach: simple triage, followed by structured documentation.

2. Who is involved: LAA, LAMal, supplementary insurance, civil liability insurance?

2.1 When the LAA intervenes

If the event meets the definition of an accident, accident insurance covers treatment costs (benefits in kind). The SME Portal ( admin.ch ) reminds users that accident insurance covers treatment costs and pays daily allowances in case of disability.

In a dental context, this typically covers: shocks, falls, blows, sports accidents, and work-related or non-work-related accidents (depending on the employee's coverage status). Suva explicitly addresses "dental accidents/dental trauma" and the claims assessment process.

2.2 When LAMal can intervene (but within a limited framework)

The FOPH reminds us that dental care is not, as a general rule, reimbursed by mandatory health insurance; for dental care in case of accident, it is only reimbursed if no other insurance covers it.

Implications for SMEs: if accident insurance (LAA) provides coverage, health insurance (LAMal) should not become the default "plan B". Effective management involves correctly classifying the event from the outset.

2.3 When supplementary insurance (dental or supplementary LAA) comes into play

If it is not an accident in the legal sense (for example, wear and tear, illness, or an event without extraordinary external factors), coverage may fall under supplementary insurance (according to the individual contract). On the employer's side, supplementary accident insurance (LAA) can extend certain benefits, but it does not "create" an accident: it is based on the existence of an LAA-related event according to the contract's terms. Example of wording in supplementary insurance terms: the extension applies to accidents compensated by the LAA. (LAA reference)

2.4 And what about civil liability?

When damage results from a third party (e.g., defective product, fault of a responsible party), a liability claim may exist. In practice, for SMEs, the important thing is not to mix up the procedures: first, the primary coverage is declared and secured, then any recourse is managed if necessary (often handled by the insurer).

3. Typical Coverages and Exclusions: The Hard Point of “Chewing Accidents”

3.1 Chewing: why it's controversial

The Federal Court recalled that in accident insurance, a dental injury occurring during chewing is not automatically an accident: an extraordinary external factor is required.

3.2 Case law example: the unpitted olive

In case 8C_191/2018, an insured person broke a tooth while biting into an unpitted olive in a ready-to-eat salad. The dispute specifically concerns the "extraordinary" nature of the external factor and its classification as an accident.

This type of case shows a very concrete governance point: a "chewing" case must be documented as a risky case (evidence, circumstances, product, photos, witnesses), otherwise the decision will be slow or unfavorable.

3.3 The most frequent de facto exclusions (without figures, without promises)

Without going into contractual lists specific to each insurer, three reasons recur in practice:

• absence of any identifiable sudden event (more likely wear and tear/fragility)

• non-extraordinary external cause (an element “normally expected” in the food)

• Insufficient file (vague circumstances, lack of evidence or precise dental report)

Suva insists on the correct qualification of the case and the measures to be taken after a dental injury, precisely because the line is thin.

4. SME Method: Manage, document, monitor (from triage to decision)

4.1 Operational triage in 4 questions

1. Was there a sudden and datable event? (fall, shock, impact)

2. Was the injury unintentional?

3. What is the external factor (object, impact, food item)? Is it “extraordinary” within the meaning of case law?

4. Which reporting channel: LAA (employer/accident insurer) or other?

4.2 What needs to be documented

Box:

• factual description: date/time, place, activity, mechanism (impact, fall, chewing)

• photos (if relevant), product/packaging for chewing, testimonials

• Dentist's report: diagnosis, causal link, treatment planned, damage to prosthesis/crown (without inventing a scale)

• certificate of incapacity for work if on sick leave

• Insurer's exchanges and decisions (traceability)

4.3 Control panel (without figures)

Type of situation, Key question , Most likely route , Risk of dispute , Documentation priority

Fall/impact (sports, work, commuting) – clear external factor? LAA low to medium standard

Impact received (object, collision): datable event? LAA reinforced average

Chewing (kernel, fragment) - an extraordinary factor? LAA or maximum high refusal?

Progressive pain/cavity/wear, no sudden event outside of LAA, low minimal (orientation)

5. Two mini case studies (SMEs)

Case 1: Broken tooth during a fall (quick decision)

An employee slips on a staircase, falls, and breaks an incisor. This is a sudden, unintentional event with a clear external cause (fall/impact). The response involves immediate reporting to the Swiss Accident Insurance Act (LAA), obtaining a dental report, taking photos if necessary, and following up on decisions. The "accident" scenario corresponds to the definition provided by the Swiss National Accident Insurance Fund (Suva).

Case 2: Tooth broken while eating (risky decision)

An employee breaks a tooth while eating a ready-to-eat product. The debate will focus on the extraordinary nature of the incident. Management: keep the food/packaging, precisely document the incident, request a detailed dental report, and prepare the company for a more lengthy investigation (or even a rejection) depending on the legal assessment, as illustrated by case law.

Guidelines and checklist

Step Objective Action Evidence to retain

1. Triage: Classifying Accident vs. Non-Accident - 4 Triage Questions - Dated HR Note

2. Declaration: Open the correct channel for LAA declaration if probable accident. Acknowledgement of receipt.

3. File to reduce the risk of refusal: dental report + circumstances, single PDF file

4. Monitoring, managing deadlines and decisions, follow-ups, case log, tracking log

5. Coordination: avoid duplication of LAA/LAMal insurance, clarify "who pays", final decision archived

Common mistakes and how to avoid them

1. Declare under LAA without describing the external factor

To do: write the mechanism in 3 factual lines, not a conclusion (“accident”). Case law requires an analysis of the extraordinary external factor.

2. Treat chewing as an “automatic” process

To do: strengthen the case (product, evidence), because this is a subject of dispute.

3. Switching too quickly to the "default" LAMal plan

To do: first check for the existence of another insurance policy (LAA). The FOPH clarifies the principle of subsidiarity for dental accidents.

4. Do not archive the decision

To do: keep decisions and documents: a dental case can be used again (internal control, dispute, relapse).

Questions to ask your insurer/broker (10 questions)

1. What is your analysis grid for a dental case under LAA (particularly mastication)?

2. What minimum documents do you require to make a quick decision?

3. How do you assess the “extraordinary external factor” in practice?

4. What is the recommended channel (portal, form, dentist) for dental care?

5. How to treat a tooth/prosthesis that was already weakened before the event?

6. What factors most often lead to a refusal (lessons learned)?

7. In case of refusal of LAA, what alternatives do you recommend (supplementary, other insurance)?

8. How to coordinate LAA and LAMal without duplicate billing?

9. What are the time limits and escalation points for a contested decision?

10. Can you audit our internal processes for reporting and documenting dental claims?

Conclusion

A dental case is only considered an “LAA” (Accident at Work Law) if it meets the legal definition of an accident and if the case file demonstrates the extraordinary external factor involved (particularly chewing). For an SME, the right decision is not to “take a chance,” but to apply a stable method: manage (triage), document (evidence), and monitor (log and decisions).

Next step (soft): formalize an internal “dental case” checklist and link it to your claims management process, in order to gain consistency and responsiveness.