LAA: What is an occupational disease, who is involved? What are the coverages and exclusions?

Introduction

In SMEs, a suspected occupational disease often creates a gray area: is it "the disease" (health insurance), is it "the work" (accident insurance), who pays, who decides, and what needs to be proven? The answer is not intuitive. Under the Federal Law on Accident Insurance (LAA), an occupational disease is not simply an illness "occurring at work," but rather an illness that meets specific and documentable causal criteria.

By the end of this article, you will know how to decide and act: which insurer intervenes, what benefits are involved, what exclusions are common, and how to structure a robust case with a simple “manage, document, follow” method.

1. Occupational disease LAA: definition and recognition criteria

1.1 The principle: it is the accident insurance that classifies the work-related cause

Suva reiterates a key governance point: accident insurance is responsible for assessing the occupational cause of an illness. If the occupational disease is recognized, accident insurance covers not only the treatment costs, but also daily allowances and, where applicable, pensions and compensation.

As a consequence for SMEs: the first decision is not “which doctor”, but “which insurance channel” and “which file”.

1.2 Two entry points: list (OLAA) and general clause (art. 9 para. 2 LAA)

To understand the logic, remember that there are two ways to recognize:

• Diseases caused by harmful substances or certain types of work, with a list established by the ordinance. Suva and occupational safety coordination bodies refer to this LAA/OLAA framework.

• Other diseases: the Federal Coordination Commission for Occupational Safety (CFST) recalls the rule of art. 9 para. 2 LAA: other diseases which are proven to have been caused exclusively or predominantly by the exercise of professional activity are also considered occupational diseases.

1.3 The technical point that tips the scales in a case: the “preponderant” causality

A medical publication from Suva (distinction between accident LAA / illness LAMal) specifies how causality is assessed in practice and quotes the Federal Court: a “preponderant” causality exists only when occupational factors weigh more than all other contributing causes, therefore more than 50% across the entire spectrum of causes.

For an SME, this translates into a concrete requirement: to document exposure and work history in a usable way, not just describe symptoms.

2. Who intervenes and who pays: roles of the employer, the accident insurer, and the LAMal (Swiss Health Insurance Act)

2.1 LAA: Insurance obligation and employer responsibilities

Suva reminds us that, in accordance with the LAA, all workers in Switzerland are compulsorily insured by their employer against accidents and occupational diseases.

The SME Portal ( admin.ch ) reminds us of the LAA/OLAA framework and the obligation to insure employees (at least for occupational accidents) and the logic of premiums and coverage.

Governance benchmark: even if the disease “develops” over months, the insurance system must be in place continuously (correct affiliation, competent insurer, internal process).

2.2 The accident insurer: the key player in the recognition decision

The accident insurer is responsible for the investigation: collecting medical information, analyzing exposure, and making a decision regarding recognition of the injury. Suva also emphasizes that many cases go unreported, even though reporting to accident insurance is crucial to prevent treatment costs from being covered by health insurance.

HR decision: put in place a single “entry point” (often HR/claims management) and avoid fragmented claims.

2.3 And what about LAMal in all of this? Coordination and risks of a switchover

When an occupational disease is not recognized, the case typically falls under the health insurance system (LAMal), with a different benefits framework. Suva emphasizes the distinction between accident insurance (LAA) and health insurance (LAMal) and the assessment of the occupational cause.

SME management: plan for a “recognized” scenario and a “not recognized” scenario, without waiting for the final decision to organize HR continuity (certificates, job adaptations, monitoring of absence).

3. Accident insurance coverage in case of occupational illness: what is at stake for the company

3.1 Typical benefits: care, loss of earnings, annuities (without promising amounts)

The SME Portal summarizes that accident insurance covers medical expenses due to an accident and, more broadly under LAA, compensation for health and financial losses in the event of an accident or occupational disease.

Suva specifies, for recognized occupational diseases, the coverage of treatment costs, daily allowances and possible annuities/compensation.

Governance: the main impact for SMEs is the continuity of salary/compensation and the stability of the case (less back and forth between insurers).

3.2 Prevention and “exposure record”: a management asset

SECO reminds us that the prevention of accidents and occupational diseases is regulated by the LAA and by the Ordinance on the Prevention of Accidents and Occupational Diseases (OPA).

Translation for SMEs: Prevention is not only an obligation, it is also a means of proving liability. A risk inventory, job descriptions, and exposure monitoring can become decisive when a case is being discussed.

4. Exclusions and reasons for refusal: understanding areas of vulnerability

4.1 The most frequent reason for refusal: insufficient or undocumented causality

The core of the exclusion is not "the illness" itself, but the lack of proof of a work-related link according to the LAA criteria. The CFST reiterates the requirement of an exclusive or clearly predominant causal link for illnesses not listed (Art. 9 para. 2 LAA).

And Suva clarifies the threshold for assessing predominant causality as discussed by the Federal Court (more than 50% in all cases).

4.2 Confusion between “work-related illness” and “occupational disease”

An illness that manifests at work (fatigue, pain, disorders) is not automatically considered work-related. Without provable exposure or sufficient evidence, the case remains a common-sense illness, not recognized under the LAA (Accident Insurance Act).

4.3 Channel error: reporting too late or to the wrong person

Suva indicates that accident insurance is competent and that the declaration is important.

For an SME, the risk is operational: delays, lost parts, inaccurate documentation, and multiple versions. Hence the importance of a standardized internal process.

5. Two mini case studies (SMEs)

Case 1: Plausible “listed” illness, file presented and decision expedited

Situation: An employee has worked for years in a position involving documented exposure to a typically monitored substance or process (without naming the substance here). The company has job descriptions, PPE, training, and preventive measures in place.

Piloting:

• Report any suspected occupational disease to the accident insurer without delay

• Attach the exposure file (position, duration, measurements, certificates)

• Ask the treating physician for a structured report (diagnosis, causal hypothesis)

Expected result: faster instruction, because the "work" parts are already framed (health follows later).

Case 2: Disease not listed, causality disputed and need for “clearly preponderant” evidence

Situation: chronic disorders with multiple possible causes (work and private factors).

Piloting:

• Clarify activity history, job changes, and exposures

• Stabilize the narrative (chronology) and avoid contradictions

• Anticipate a need for expert opinion/specialist advice, as the “exclusively or clearly predominant” proof is demanding (CFST).

Governance decision: organize HR continuity (job adaptation, monitoring, confidentiality) even if LAA recognition is uncertain.

What needs to be documented

• Chronology: onset of symptoms, worsening, cessation, resumption

• Job description: tasks, processes, substances/agents, repetitive movements, constraints

• Evidence of exposure: safety data sheets, inventories, training certificates, PPE, internal controls

• Evidence of prevention: risk assessments, measures implemented (OPA)

• Medical: diagnosis, examinations, causality assessment, work capacity

• Administrative: declarations, decisions, exchanges, tracking log

Guidelines and checklist

Step Objective Action SME Expected Outcome

1. Triage: correctly distinguish between "work-related" and "occupational" illnesses; factual HR note

2. Channel to put the correct insurer in the loop: declaration to the accident insurer (LAA), acknowledgement of receipt

3. Work file proving exposure package “job + exposures + prevention” (OPA) structured file

4. Medical file: stabilize the diagnosis, structured medical report, consistent medical documents

5. Monitoring, managing deadlines and decisions, case log, regular updates, complete traceability

6. Scenarios to avoid HR disruption: “recognized” / “unrecognized” operational continuity plan

Common mistakes and how to avoid them

1. Wait for the "correct final diagnosis" before declaring

To do: report as soon as there is a structured suspicion; Suva emphasizes the importance of reporting to accident insurance.

2. Send only medical documents

To do: attach an exposure and prevention file; this is often what is missing.

3. Multiply the number of people involved and versions of the story

To do: an internal case manager, a single timeline, a stable factual version.

4. Confusing prevention with evidence

To do: archive the prevention (OPA) and post elements, as they are also useful in case of litigation.

Questions to ask your insurer/broker (10 questions)

1. What are your specific criteria for classifying an occupational disease under the LAA?

2. In which cases do you use the “OLAA list” versus “art. 9 para. 2 LAA” route (clearly preponderant evidence)?

3. Which "work" elements most accelerate instruction (workstation, exposure, prevention)?

4. How do you assess the predominant causality (reference to practice/TF)?

5. What timeframes and decision-making steps should we anticipate (triage, expertise, decision)?

6. What reporting errors do you most often observe on the employer side?

7. How do you coordinate care with LAMal if recognition is being discussed?

8. What level of detail do you expect from a medical report to make a decision?

9. What elements of prevention (OPA) do you expect to document the exposure?

10. Can you audit our system (at-risk positions, documentation, reporting process) to reduce grey areas?

Conclusion

Under the Accident Insurance Act (LAA), an occupational disease is managed like a causality case: either it corresponds to substances/work covered by the ordinance, or it must be proven to be caused exclusively or predominantly by professional activity. The accident insurer is the key player, and if recognized, benefits can be more extensive than under health insurance (treatment, daily allowances, annuities depending on the situation).

Next step (soft): map your exposure positions, formalize a standard “occupational disease” file (work + medical), and integrate it into your claims management process to gain clarity, consistency and responsiveness.