Relapse in income protection insurance: understanding, managing, deciding

Introduction

In a small or medium-sized enterprise (SME), sick leave can already represent a significant financial risk. However, when an employee returns to work and then falls ill again with the same or a related condition , it is considered a relapse . This concept, while common in practice, is not specifically defined by federal law in sickness loss-of-earnings insurance, but it is addressed contractually. The aim of this article is to help managers, CFOs, and HR professionals understand what a relapse is, the insurer's acceptance criteria, how to document the case, and how to manage this risk to avoid benefit denials.

What is loss of earnings insurance due to illness?

Before discussing relapse, let's review the general framework of loss of earnings insurance in Switzerland:

Essential definitions

• Loss of earnings insurance for illness is a contract designed to compensate for the loss of income when a person is temporarily unable to work due to illness or accident.

• It is often taken out by the employer for their employees or by a self-employed person on an individual basis.

• Daily allowances are paid according to the terms of the contract after a defined waiting period and up to an agreed maximum duration (e.g. often 720 days out of 900 consecutive days, depending on the contract).

• In the absence of a collective agreement, the employer remains obligated to continue paying wages according to the Code of Obligations.

The absence of a clear legal definition of "relapse"

The official Swiss sources consulted (SECO, insurance portals, professional guides) describe incapacity for work and loss of earnings insurance, but do not legally define the concept of relapse in this context. It depends on the contractual clauses of the insurance policies and the insurer's interpretation. This is a practical reality often acknowledged in claims handling procedures, but not codified at the federal level.

How is relapse addressed in contracts?

A "relapse" occurs when:

Operational cases

• The insured returns to work after a covered work stoppage, then suffers a new incapacity for the same medical cause or a direct aggravation.

• Relapse may be treated as a continuation of the same case , rather than a new case, if it occurs within a specified interval in the policy (often 3 to 6 months but depends on the contract).

Standard clauses (to be checked in the policy)

Insurers often add clauses such as "bridging period" or "continuity period" between two periods of sick leave. If a relapse occurs during this period, it is considered a continuation of the first period of sick leave, thus avoiding a new waiting period.

Management method: when analyzing contracts, identify these clauses as documentary requirements . Accurately documenting dates, medical diagnoses, resumptions, and new suspensions is crucial.

Operational guidelines for managing a relapse

Key steps

1. Identify the initial event and set the end date of the covered stoppage.

2. Compare medical diagnoses – determine if the relapse is related to the same pathology.

3. Check the contractual clauses regarding continuity and connection periods.

4. Document the claim file with medical certificates, reports, justification of the link.

5. Submit to the insurer before the expiry of the contractual period of a possible repossession.

Without precise legal data, it is the contract that determines whether the event is a relapse or a new case.

Mini case studies

Case 1: Employee and same illness

An employee returns to work after a four-week absence due to lower back pain. Two months later, he complains of the same symptoms, which are confirmed by a doctor. If the contract includes a 90-day waiting period, the second period of incapacity can be considered a relapse and not subject to a new waiting period. In this case, the insurance continues to provide benefits under the same policy.

Case 2: Independent and related pathology

A self-employed individual on sick leave (loss of earnings due to illness) returns from sick leave for bronchitis. Three weeks after returning to work, he develops related pneumonia. Recognition of a relapse will depend on the medical assessment and the terms of the contract. A contract with a social or medical liaison period is more likely to be recognized as a relapse.

What needs to be documented

Documenting a case of relapse requires:

• Medical certificates for both periods of leave;

• Detailed report on the link between primary and secondary pathologies (treating physician);

• Specific dates for resumption and new shutdown;

• Contract clauses read and annotated.

Guidelines and actionable checklist

Step Task Document to produce

Preparation: Identify relapse criteria in the contract. Excerpt from the continuity clause.

Clinical analysis; Medical link between sick leave; Certificates + medical opinion

Timing: Compliance with contractual periods; Dated schedule of stops

Communication Detailed claim form + supporting documents

Common mistakes and how to avoid them

Mistake 1: considering any new incapacity as an automatic relapse.

Solution: check the wording of the contract and the maximum possible interval.

Error 2: Sending incomplete certificates.

Solution: ask the doctor for a structured report explaining the medical link and diagnoses.

Mistake 3: forgetting the contractual waiting period.

Solution: anticipate the processing by planning the submission before the deadline.

Questions to ask your insurer/broker (10)

1. What is the definition of "relapse" in my policy?

2. What is the planned connection time between two stops?

3. Does a new waiting period apply in the event of a relapse?

4. What medical documents are accepted to establish the link between the two arrests?

5. How are diagnoses evaluated (internal/external medical expertise)?

6. What are the response times for a decision from the insurer?

7. How is the remaining duration of benefits calculated if a relapse is recognized?

8. What are the specific exclusions related to relapses?

9. Is there an impact on future bonuses after a relapse?

10. What is the appeal procedure in case of refusal of recognition?

Conclusion

The concept of "relapse" in income protection insurance is not a standard legal concept in Switzerland , but it is a crucial contractual concept to understand when managing income risks in SMEs. Knowing how to read the clauses, meticulously documenting cases, and asking the right questions of your insurer will help you avoid unpleasant surprises. A concrete next step is to have your current contracts audited to identify these relapse clauses and formalize an internal claims management system.