Friday, 25 February 2011 01:11

Country Case Study: Sweden

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The Swedish official system for compensating workers with occupational injuries is regulated by law—the official act on occupational injury insurance (Official Act on Occupational Injury Insurance 1993). The system is organized to function as an integral part of the framework of Swedish national social security, receiving monetary contributions from levies on employers and a basic funding through government revenue sources.

The objective of occupational injury compensation, according to the law, is to compensate for loss of income and for assessed loss of earning capacity. In addition, a large part of the labour market has a supplementary system, based on collective agreements between the social partners on the labour market (employers organizations in the public and private sectors and corresponding trade unions) for compensation to the insured population for pain and suffering, disability and handicap and other types of incapacity. This collective insurance programme is referred to as the Labour Market No-Fault Liability Insurance (TFA). It operates on a no-fault basis, meaning that, for recognition of a claim, there is no requirement on the claimant to prove negligence on the part of the employer or anyone else involved in the claim at issue. This supplementary insurance system is not required or regulated by law, and is operated jointly on a partnership basis by the employers’ organizations and the trade unions.

The following discussion will focus on the official legislated system in Sweden.


The official system operates on the basis of notifications submitted by those insured when the injury occurs. The insured population consists of everyone employed on the labour market at the point in time when the disease or health problem manifests itself. The notification—which in practice means that the injured person fills out a form—is handed to the employer, who is obliged to forward it to a local or regional social insurance bureau. After due examination of the documentation and evidence appended to the notification, a decision is taken by a regional Social Insurance Board, approving or rejecting the claim.

If the claimant or somebody else involved is not satisfied with the decision taken by the Social Insurance Board, the case may be referred to an administrative court of appeal. This court is part of the Swedish judiciary.

The Swedish system in force as of 1 January 1993 is designed to operate on the basis of three fundamental principles:

  • the concept of occupational injury
  • the concept of hazardous agent at work
  • the concept of causality of hazardous agent with regard to the disease at issue.


Occupational Injury

The occupational injury concept has two main components, namely occupational accidents and occupational diseases. The operative part of the concept lies in the term injury. This may be caused by either an accident at work or a hazardous factor causing a disease and operating at the present workplace or in some previously held work. The injury concept thus encompasses both consequences of bodily harm caused by accidents and diseases or impairments viewed as caused by other agents, such as physical, chemical, psychological or other types of environmental factors operating at work. The disease concept as implemented has a broad scope. It covers both diseases, as classified by, for instance, the WHO classification of diseases, and, in addition, functional disturbances, ailments or impairments perceived by the individual as health aberrations. This means that there is no officially defined list of occupational diseases or work-related diseases in Sweden. Any disease or impairment, as referred to above, may be regarded and recognized as occupationally induced, depending on the evidence presented to support a claim for economic compensation. This means that, in addition to a disease or health problem directly caused by work or workplace factors, the following factors may be included in the concept of occupational injury:

  • early manifestation of disease that is work-related but which also occurs in the general population without any association to working conditions
  • disease or functional disturbances causally unrelated to working conditions but where workplace factors may contribute to accelerating or worsening the disease.


This broad occupational injury concept has been applied since 1977, and it was not changed in the amended law in force since 1 January 1993. This means that there is no closed list of occupational diseases. Nor is any distinction made between diseases that are occupationally caused and those that are work-related. Recognition of a disease or functional disturbance reported by an injured person (who is covered by the social security system) as an occupational injury depends on the evidence presented by the claimant.

The use of this broad concept aims at making the system capable of identifying any health problem that may have been contributed to or caused by conditions at work.

The Hazardous Agent at the Workplace

The recognition of an occupational injury is dependent on identifying a hazardous agent at the workplace. If such an agent cannot be identified and assessed to be sufficiently relevant to the type of injury at issue, the disease or functional impairment cannot be approved as a case of occupational injury.

Hazardous agent implies any physical, chemical or other agent which may adversely affect the health status of the employees. There are some limitations with regard to scope. The law does not consider to be hazardous agents factors related to closing down enterprises, industrial disputes, lack of social support, or non-adaptation to prevailing workplace culture and other similar conditions.

The requirements in the law in force as of 1 January 1993 have been defined as: “A hazardous agent is a factor which in high probability may cause disease or impairment.”

This phrasing represents—in comparison with the law in force until 31 December 1992— an enhanced level of requirement on the evidence to be considered by the social insurance boards. It is also made explicit in the explanatory texts attached to the legislation that the assessments of hazardous properties of the agent under consideration should conform to a mainstream of opinion—or ideally a consensus—among qualified medical experts. If there are diverse and dissenting expert opinions on the assessment of hazardous properties the criterion of high probability will not be satisfied.

The assessment of the hazardous agent also implies an assessment of quantity. The exposure to the agent at issue is to be considered with regard to duration, intensity and other criteria judged to determine hazardous properties.

Causal Relationship

Once the existence or previous occurrence of a hazardous agent has been established as highly probable—which in this context also includes an assessment of quantity—the next step is to arrive at a conclusive judgement on the plausibility of a causal relationship in the individual case at issue. The general rule to follow is that the weight of evidence should be in favour of causality for recognition of the disease or health problem as an occupational injury. According to the earlier legislation, in force until 31 December 1992, the causality concept was significantly more flexible. Causality was presumed once the presence of a hazardous agent had been accepted as a probability and no evidence to the contrary could be presented. The burden of evidence has now been reversed. The requirement is now a positive weight of evidence in favour of a causal relationship. In practice it means that a need arises to also consider alternative causal explanations. This may include, for instance, aspects of the claimant’s lifestyle and leisure time activities or personal situation in general.

Assessment of Individual Vulnerability

The basic principle in implementing the legislation is that all insured are to be accepted, with their constitutional weaknesses and vulnerabilities. This principle may give rise to considerable difficulties, for instance in assessing health problems related to hypersensitivity reactions and allergic diseases. It may be very difficult to make informed judgements of the relative contributions from the person’s constitution and environmental/occupational factors, respectively. The difficulty in such instances arises in defining and assessing the properties of the hazardous agent. The agent (for instance, exposure to a workplace chemical or an air pollutant) may be harmless to most exposed persons but not to those who are particularly susceptible.

Occupational Injury Compensation and Preventive Action

The Swedish legal system for paying compensation to injured persons and the legal systems for enforcing occupational health preventive measures are separate and not directly related. The rate of workplace accidents or occupational injuries does not affect the level of financial contributions by employers or enterprises. This is sometimes referred to as a flat rate of payment.

The compensation system functions only for payments to persons with recognized occupational injury and has no bearing on enforcement of preventive action.

The same rules applies for occupational rehabilitation, regardless of whether the disease or injury has been recognized as an occupational injury or not. The employer has an obligation in principle to take steps to initiate a rehabilitation process when workers have been absent from work for 4 weeks or more.

The Role of Social Partners

The social insurance legislation accords the social partners (i.e., employers’ organizations and the trade unions) no role in rejecting or approving compensation claims for occupational injury. On the company level the employer is obliged by law to pass on to the social insurance system any claim for occupational injury submitted by an employee. The trade union organizations commonly provide advice and support to claimants among their members. Such assistance includes drafting claims, examining workplace conditions and giving advice.

The Present Situation

Since the present legislation has been officially in force, the supervising authorities have to a large extent been busy dealing with the considerable accumulation of injuries reported under the previous legislation. This means that there is only limited experience from the present law and the official public statistics are incomplete.

At the present time there is a need to elaborate practical guidelines for implementing the legislation. The Swedish Labour Market Insurance (TFA) trust—jointly with the National Institute for Working Life—recently published a report describing the extent of knowledge regarding disease and occupational factors for selected disease categories. At the present time such descriptions are available for tumour disease, diseases of the nervous system, diseases of the lung and pleura, malignant disease, cardiovascular disease, skin disease and work-related loss of hearing (National Institute for Working Life and Labour Market No-Fault Liability Insurance Trust 1995). A further volume on psychological disturbances and stress-related mental disorders is in preparation.

Before the change of the law on compensation for occupational injury, the level of occupational diseases in the early 1990s was around 50,000 to 55,000 claims recognized annually. The number of reported and recognized occupational accidents during this time was 20,000 to 22,000. Musculoskeletal disorders constituted a major part (80%) of the reported occupational diseases.

One important factor affecting levels of reported occupational injuries is the automatic coordination of payments received from the occupational injury system and the general sickness benefit system, respectively. In 1993 the coordination time was increased from 90 days to 180 days. This implies that an injury or disease, although causally related to work, is not compensated unless it leads to long-term absence from work (more than 180 days) or to permanent disability. The compensation during the first 180-day period is covered by the general sickness benefit scheme.

It is expected that the number of reported occupational injuries and, consequently, of recognized cases will decline significantly, starting in the near future. The official statistic routines have not yet been adapted to the changes in legislation. This means that the number of notifications and recognized occupational injuries recorded at the present time consist of a combination of claims under the previous legislation and claims that are settled on the basis of the legislation in force as of 1 January 1993. As a consequence, the official statistics cannot at the present time describe the impact of the amendments in the legislation referred to above.



Friday, 25 February 2011 01:02

Workers' Accident Compensation in Japan

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Summary of Coverage and Goal


Hazards covered

The workers’ accident compensation insurance system in Japan is under the control of the government, based on the Workmen’s Accident Compensation Law (1947). It gives workers insurance benefits in order to protect them promptly and fairly against injuries, diseases, disabilities or deaths incurred “because of duty”. The definition of “because of duty” is not stipulated by the provisions in related laws. The criteria used by the government administration make it clear, however, that the system is applied to injuries, disabilities or deaths that result from employment, namely “during the duty situation in which workers are under the control of an employer according to work contracts” and “due to an accident or a circumstance caused by this duty situation”. Thus the system is applied to all the injuries, disabilities and deaths incurred while workers are working or commuting to work. It is also applied to “diseases or disorders to workers engaged in work with hazards that can harm health from sudden or chronic action of such hazards”. These because-of-duty diseases include those caused by injury resulting from employment and occupational diseases caused by physical, chemical and biological agents or specific forms of work performance, and those apparently caused by work.

Industries and workers covered

The workmen’s accident compensation insurance system is applied compulsorily to all workers who are employed in enterprises to which the Labour Standards Law is applied and receive wages. They include those regularly or temporarily employed, daily-wage workers, and both full-time and part-time workers, irrespective of the size of enterprises.

All industries are covered by the system, except part of the agriculture, forestry and fishery industries. The exceptions are agricultural undertakings individually owned and employing less than five workers, forestry undertakings not employing regular workers, and fishery undertakings employing less than five workers and operating in sea areas without significant accident. Government employees, local government employees and sailors are covered by separate workmen’s compensation systems.

Types of payment

The following types of insurance benefits are available for on-the-job injuries and diseases:

  • medical benefit: in principle, medical treatment (in exceptional cases cash reimbursement for treatment expenses)
  • temporary disability benefit: when unable to work and earn wages because of treatment
  • injury and disease compensation pension: when not recovered one-and-a-half years after starting to receive treatment and the extent of disabilities remains at a certain level
  • physical handicaps compensation benefit: according to the degree of physical handicap the workers are left with
  • bereaved family compensation benefit: to the spouse, children, parents, grandchildren, grandparents or brothers and sisters who had been supported by the income of the workers concerned
  • expenses for funeral rites
  • nursing compensation benefit: for full-time or occasional nursing in the case of a grade 1 or grade 2 physical handicaps compensation pension or an injury and disease compensation pension.


For injury, disease, disability or death incurred during commuting, the following benefits are paid: (a) medical benefit; (b) temporary disability benefit; (c) injury and disease pension; (d) physical handicaps benefit; (e) bereaved family benefit; (f) funeral rites benefit; and (g) nursing benefit. The details of these benefits are the same as in the case of on-the-job accidents or occupational diseases.

The income benefits are calculated on the basis of the average daily wage of the workers concerned. The temporary disability benefit amounts to 60 of the average daily wage and is given starting from the fourth day of absence from work, together with the temporary disability special supplement equivalent to 20% of the average daily wage (the employer must pay compensation equivalent to 60% of the average wage for the first three days). The amount of injury and disease compensation pension, given when workers do not recover within one-and-a-half years, ranges from 245 to 313 days of the average daily wage. The physical handicaps benefit ranges from 131 to 313 days of the average daily wage. The amount of the bereaved family compensation lump sum ranges from 153 to 245 days of the average daily wage.

The temporary disability benefit, the pension and the lump sum benefit are subject to the sliding scale system which reflects the movement of wages. In cases where the average pay of all the workers for a quarter of the year surpasses 110% or falls short of 90% of the average pay for the quarter to which the day belongs when the worker concerned was injured or taken ill, the average daily wage used for the calculation of temporary disability benefit is automatically revised according to the fluctuating average pay rate. Similar calculations are done for pension and lump sum benefits when the average pay of all the workers for a year surpasses or falls short of the average pay for the year in which the worker concerned died or became ill.

Other aspects

Welfare services

The purpose of the Workmen’s Accident Compensation Insurance is to advance the welfare of workers by promoting return to work or social life of the victims, to give support to them and their bereaved families and to secure proper working conditions. Therefore the system has separate provisions for various welfare services and some preventive measures. Some of these services are managed by the Labour Welfare Services Association, to which the insurance system supplies the funds. Welfare services include the establishment and management of employment injury hospitals, spinal cord impediment centres, rehabilitation workshops, housing loans, relief funds for education and long-term family nursing, installation and operation of special care facilities for workers suffering from employment injuries, home help services and nursing device leasing.

Extension of coverage

Employers of small and medium-sized enterprises and self-employed persons to whom it is appropriate to give the same protection as workers considering the nature of their business may be covered by the workers’ compensation insurance. Entry into the insurance system is allowed to employers of small and medium-sized enterprises which entrust insurance procedures to a labour insurance business association, as well as to the self-employed who join an organization capable of executing insurance procedures.

Workers who are dispatched overseas by employers in Japan or dispatched as representatives for overseas small and medium-sized enterprises are covered.

Description of the System


The need for compensating workers for on-the-job injury was first noted by the Factory Law (1911) and the Mine Law (1905). These laws stipulated that employers were responsible for providing sufferers of industrial injuries with assistance. The Health Insurance Law (1922) covered short-term injuries incurred on or outside the job by workers engaged in enterprises to which these laws were applicable. The coverage was later extended to long-term injuries and to civil engineering, construction and transportation workers. A new stage began when the two principal laws described below were enacted in 1947, following the termination of the Second World War. The Labour Standards Law introduced for the first time the idea of employers’ liability and compensation in place of “assistance” in the case of employment injury. The Workmen’s Accident Compensation Insurance Law set up insurance within the jurisdiction of the newly established Ministry of Labour. The insurance system has been improved by repeated revisions of the law. It operates as a system independent from the social security programmes of the country.

Types of insurance coverage

Workmen’s Accident Compensation Insurance is a state insurance system administered by the government. The scope of the insurance extends to all on-the-job accidents and diseases and commuting accidents. It covers both medical and cash income benefits. The medical and rehabilitation costs for workers suffering from injuries or diseases covered by this system are paid by the insurance, a separate treatment not covered by health insurance schemes.

Employers covered by Workmen’s Accident Compensation Insurance are no longer liable for compensation stipulated by the Labour Standards Law for cases compensated by this insurance. However, there are collective agreements that provide for supplementary compensation beyond the levels provided by the state insurance. Furthermore, there are a number of private enterprises that join the compensation insurance schemes managed by private insurance companies.

Disputes about the amount of supplementary compensation for victims of occupational injuries and disease and their families are often brought before the court.

All types of employment and commuting injuries are covered. As for diseases, there is a list of occupational diseases attached to Article 35 of the Enforcement Ordinance of the Labour Standards Law (revised in 1978). The list is comprehensive and covers in effect all types of work-related diseases. The following nine categories are mentioned:

  • diseases caused by injury resulting from employment
  • diseases caused by physical agents (13 items)
  • diseases caused by specific forms of work performance in which an extreme physiological tension is involved (5 items)
  • diseases caused by chemical substances and others (8 items)
  • pneumoconiosis caused by work in places where dust is dispersed, and diseases complicated by pneumoconiosis stipulated by the Enforcement Ordinance of the Pneumoconiosis Law (1960)
  • diseases caused by bacteria, viruses and other pathogenic organisms (5 items)
  • diseases caused by carcinogenic substances or agents, or work performed in a carcinogenic manufacturing process (18 items)
  • other diseases designated by the Minister of Labour
  • other diseases apparently caused by work.


Role of social partners

Development of compensation principles

Workmen’s Accident Compensation Insurance started as an insurance system financed wholly by employers. Partial payment by the government began in 1960, when long-term injury and disease compensation was adopted and lump sum payment was replaced with annuity payment for the physically handicapped. In 1965, government subsidies were introduced for the expenses of administering the workers’ compensation insurance and for insurance payments. This was accomplished by serial amendments of the Workmen’s Accident Compensation Law, which in the beginning was applicable only to enterprises regularly employing five or more workers, except part of the agriculture, forestry and fishery industries. Any such enterprise is obliged to automatically join the insurance system as soon as its business starts. Administration of the insurance system is supervised by the Bureau of Labour Standards of the Ministry of Labour. Penalties are applied in the case of violations. Thus the roles of employers and workers are basically what they were at the beginning of the system.

The benefits received by the injured workers and the bereaved families have been improved by several modifications of the law. These modifications improved long-term benefits and bereaved family compensation pensions, introduced the sliding scale of payments as determined by wage level changes, extended benefits to all commuting accidents, and established the special supplement system and the labour welfare services in 1976. In 1981, the adjustment rules between the workers’ compensation insurance benefit and the civil damage compensation were established. Nursing compensation benefits are being introduced.

Deciding whether an injury or disease is because of work duty is based on administrative interpretations. Those who are not satisfied with the decisions may demand an examination or arbitration by a Workmen’s Accident Compensation Insurance examiner appointed by the Minister of Labour. If they are not satisfied with the examiner’s decision, they may demand a re-examination of their case by the Labour Insurance Council. Those who are dissatisfied with the council’s decision can file a suit in court.

Mechanism for updating

The terms of operation of the insurance system are approved by the Council of Workmen’s Accident Compensation Insurance, in which employers, workers and academia are represented. The development of the system and modifications of insurance benefits are examined by the council. As a result, the Workmen’s Accident Compensation Insurance Law was revised several times as mentioned above.

Decisions of the appeal and the civil court systems concerning compensation cases contribute to updating of benefit levels and criteria.


The government collects the insurance premium from employers. The premium is calculated by multiplying the total wages payable to all the workers in the enterprise in the insurance year by the premium rate. This premium rate is determined for each category of enterprise, taking into account the past accident rates and other factors. A merit system is applied in determining the premium rate for different industries. The premium rates as of April 1992 for different industries are given in table 1.

Table 1. Premium rates of workmen’s accident compensation insurance in Japan (April 1992)


Types of undertaking

Premium rate


Felling and transport of wood






Sea fishery (except below)



Fishery by stationary nets or by culture



Coal mining



Metal and non-metal mining



Others other than below



Petroleum or natural gas mining



New construction or power plants and tunnels



New construction of railroads



New construction of roads









Wood products



Ship building and repair



Metal products









Ship loading/unloading



Other kinds of cargo handling in ports



Freight handling other than above



Traffic and transportation


Supply of electicity, gas, water or heat




Cleaning,, cremation or meat-processing






Special exceptional measures to increase or decrease the premium rate determined throughout the merit system are to be applicable starting in 1997 to small and medium-sized enterprises that have taken special measures to secure the safety and health of workers.

The injured workers or bereaved families are expected to provide the information necessary for demanding the insurance payment. The workers who receive the medical benefit for commuting injuries must have contributed to the expenses up to the limit of two hundred yen for the first medical treatment.


Some preventive measures are undertaken as part of the labour welfare services within the Workmen’s Accident Compensation Insurance. These include:

  • establishing and managing occupational health centres; and
  • supporting industrial safety and health associations.


As a result, a variety of preventive activities are supported by means of the insurance funds.

Summary of Cost Experience

The changes in the numbers of enterprises and workers covered by the workers’ compensation system and the total annual amount of insurance payments are indicated in table 2. It should be noted that sliding scales of pension rates were first applied in 1983 and that the lowest and highest limits of average daily wage of temporary disability benefit for those who need prolonged care were established in 1990. The table shows that the number of workers covered by the insurance system has been steadily increasing, but that the number of cases receiving insurance payments has decreased since 1988.

Table 2. Enterprises and workers where the workmen’s accident compensation insurance was applicable and amount of benefits in Japan

Fiscal year


Number of applicable

Number of applicable workers (thousand)

Amount of insurance benefits
(million yen)

Number of
beneficiaries (thousand)













































































In 1994, 25% of the total insurance benefits were for medical benefits, 14% for temporary disability benefits, 6% for physical handicaps compensation lump sum, 39% for pension and 14% for special grants. The distribution of the insurance benefits by industry is given in table 3.

Table 3. Payment of insurance benefits by industry in Japan


Applicable plants1

Applicable workers1

Amount of insurance benefits2






(Thousand yen)












































Supply of electricity, gas, water or heat





















1 As of end of the 1994 fiscal year.

2 As of end of the 1993 fiscal year.



Summary of Coverage and Goal


The workers’ accident compensation system in Israel is controlled and managed by the National Insurance Institute and is based on the National Insurance Law, Consolidated version (1995-5755), Chapter 5, “Employment Injuries Insurance”.

Insured persons and conditions of insurance

The workers’ accident compensation system is applied compulsorily to all employers to insure their employees (except for policemen, jailers and defence employees)—those regularly or temporarily employed, for daily or monthly wages, full time or part time, including: self-employed persons, vocational trainees, foreign residents employed in Israel, working prisoners, persons undergoing vocational rehabilitation, Israeli residents working abroad for an Israeli employer (under certain conditions), and persons whose salary is determined by law (such as Knesset members, judges, mayors), regardless of the age or nationality of the workers.

Hazards covered

This law grants benefits in order to protect the workers promptly and fairly against work-related accidents, occupational disease, disability or death.

If an insured person dies as a result of an employment injury (work accident or occupational disease), his or her relatives—widow/widower, orphans, parents and any other relatives (hereinafter called dependants)—under special conditions are entitled to employment injury benefits.

The term employment injury is applied to injuries, disabilities or deaths resulting from employment. The term work accident means an accident “which occurred in the course and as a consequence of the work and/or on behalf of the worker’s employer”. The definition in the case of a self-employed person is different and is “in the course and in consequence of the pursuit of his occupation”.

The insurance applies also to an accident that occurred to the insured person while driving, riding or walking to the workplace from home, or from the place he or she stayed overnight, or from work to home, or from one workplace to another, even if the harm caused to the employee occurred because of road hazards, so long as the demands or needs of the employee’s work constitute the main reason for the employee’s presence at the scene of the accident.

The insurance also applies to occupational diseases, defined in article 2 of Employment Injuries Insurance.

Occupational disease is defined as a disease contracted as a consequence of work or while acting on behalf of the employers, or, in the case of a self-employed person, in consequence of the pursuit of his or her occupation.

The occupational diseases are specified in a list recognized by the Institute and published in the Bylaws (regulations).

The list includes those diseases caused by injury resulting from employment and diseases caused by physical, chemical or biological agents or specific forms of work performance, and those apparently caused by work.

All employees are covered by the insurance, without exception. Every employer must insure his or her workers under each category.

Insurance coverage is mandatory also on the Government as employer, and includes all public employers.


Who is eligible

  • An insured person who suffers a work injury (work accident or occupational disease) is entitled to injury allowance.
  • An insured person who becomes an invalid as a result of a work injury is eligible for a pension or grant.
  • An insured person with a 10 per cent or higher medical disability is eligible for vocational rehabilitation. For the way the extent of the disability is determined, see below.


Conditions of entitlement for work injury benefits

Injury allowance is granted to the insured person who was injured at work or became ill with occupational disease and as a result is unable to do either the original job or any other suitable work, and did not work in fact.

Work Invalidity Benefits Grant or Pension (hereinafter called disability benefits) are paid as long as the disability has been recognized as being due to a work accident and the insured person remains disabled as a result of the injury.

The results of the injury are evaluated by comparing the fitness of the person injured at work with the fitness of a healthy person of the same age and sex. The tests determining degree of disability are a combination of the fixed percentages for each injury, taking subjective consideration into account; the loss of a particular limb is of greater weight in certain professions.

The degree of disability is determined by medical boards, of which there are two categories:

  • boards of the first instance
  • appeal boards.


The boards first determine the causal connection between the work accident (injury or occupational disease) that had to be recognized for disability purposes and the degree of the causal connection. The medical boards are independent of the body that confronts them. The medical boards are quasi-legal bodies and give rulings rather than implementing administrative action. Being quasi-legal bodies, the medical boards are subject to the control of the labour courts.

Dependants’ benefits (pensions or grants)

To be entitled to dependants’ pension, a widow must be 40 years old or over, or have a child living with her, or be unable to support herself; a widower must have a child living with him. Definition of child: Child of the insured person up to the age of 18, and up to the age of 22 in certain cases.

Vocational rehabilitation

To be entitled to vocational rehabilitation, the insured person, due to work injury, must be unable to perform the previous work or job, or any other suitable work, and be in need of and suited for vocational rehabilitation.

Insurance contributions by the self-employed

Arrears in insurance contributions rule out eligibility or reduce the rate of monetary benefits. A self-employed person not registered as such in the National Insurance Institute at the time of the injury is not eligible for benefits.

Types of benefits (payments)

The insured person is entitled to two main types of benefits under the National Insurance Law in the event of work injuries or disease:

Benefits in kind

Benefits in kind include medical attention, convalescence facilities, and medical and vocational rehabilitation.

Medical attention includes hospitalization, medications and supply, repair and replacement of orthopaedic and therapeutic appliances. The medical attention in general is provided to the extent necessitated by the work injury and its effects during the life of the insured. In fact, the medical attention is supplied on behalf of the Institute by the approved Sick Funds, recognized as approved medical service. Vocational rehabilitation is provided by the Institute either directly or through the services of other bodies.

Benefits in cash

Injury allowance: This is payment for a period of incapacity to work as a result of work injury, for a maximum period of 182 days beginning the day after the injury, calculated by day, on the basis of 75% of wages liable for insurance contributions in the quarter-year prior to the injury. The daily injury allowance has a maximum limit (see table 1).

Table 1. Recipients of work injury benefits in Israel


Dependants’ pension1

Permanent disability pensions1

Injury benefits1



Number of days paid for

Number of injured
























































































































































1 For disability and dependants’ pension, the annual figure is the number of recipients in April for each year. For injury benefits it is the total number of recipients during the year.

2 As of 1980, the annual figure given under payment disability pensions is a monthly average of recipients.

Injury allowance is not paid for the first two days after the day of injury, unless the injured person was not capable of working for at least 12 days.

Work disability benefit (work disability pension): This covers those with a disability of 20% and over—a monthly pension according to the degree of medical disability, at a rate proportionate to wages and degree of disability. Recipients of disability pensions who belong to low-income groups receive an additional “income support” supplement (see table 1).

Work disability grant: This covers those with a disability of 5 to 19%—a one-time grant equivalent to the daily injury allowance 21 ´ the percentage disability.

Special pension: This covers those with a disability of 75% and over, and those with a disability of 65 to 74% who have difficulty in walking; provides financial aid for personal expenses and transportation, up to a maximum determined by law.

Special grant: This covers those with a disability of 75% and over, and those with a disability of 65 to 74% with difficulty in walking; provides aid in purchasing a car (under special conditions), aid in solving housing problems and acquiring special accessories needed due to the disability.

Vocational rehabilitation payment: This covers aid in diagnosis and professional guidance, rehabilitation allowance during period of studies (as a supplement to disability pension) and various expenses connected with studies, such as travel, tuition and learning materials; in special cases, a grant is given for the purchase of work tools.

Benefits to dependants

Dependants’ pension: This amounts to 40 to 100% of the full pension that the insured person would have been entitled to, had he or she been 100% disabled—taking into consideration the number of children. Recipients of dependants’ pensions who belong to low-income groups receive an additional “income support” supplement (see table 1).

Dependants’ grant: This goes to a widow who has no children at home and who was not yet 40 years of age upon the death of the insured spouse—a grant equivalent to 36 months of dependant’s pension.

Marriage grant: This goes to a widow or widower who remarries—a grant equivalent to 36 monthly pension payments, paid in two instalments—the first one right after remarriage, the second two years after remarriage (right to survivor’s benefit expires).

Vocational rehabilitation: This covers vocational studies, in the form of vocational training, payment of maintenance allowance during period of study, and various expenses connected with studies.

Maintenance allowance for orphans: This goes to a child who spends most of his or her time studying in high school or in vocational training—9% of the average wage as it was on 1 January, subject to a means test of the parent. Maintenance allowance is updated by the rate of the compensation paid in the course of the year.

Bar-Mitzvah grant: This goes to a boy reaching the age of 13 and a girl reaching the age of 12, at the rate of 2/3 of the average wage as it was on 1 January, updated by the rate of the compensation paid in the course of the year.

Grant following decease: At the decease of a disabled person who had a disability of 50% or over, to whom a disability pension had been paid, or at the decease of a disabled person who was at least 65 years of age (man) or 60 years of age (woman), or at the decease of a person who had received a dependant’s allowance—a lump sum equal to the average wage as it was on 1 January preceding the day of decease, updated by the rate of the compensation paid in the course of the year, to the spouse of the deceased (or in absence thereof, to child). To recipients of income supplement, the grant is equal to 150% of the average wage as stated.

Other aspects


The main scope of the Employment Injuries Insurance is to advance the welfare of the injured persons by encouraging them to return to work. Therefore the Institute supports the services of vocational rehabilitation to the disabled persons with a medical disability of 10% or more. Furthermore, the disabled is entitled to any extra income from work without affecting his or her right to the disability pension from the Institute.

Extension of coverage

As mentioned above, persons insured by the Institute include those who are not workers in the narrow meaning of this word, such as self-employed, vocational trainees and so on.

Description of the system


The first labour law promulgated during the British Mandate in Palestine (1922 to 1948) was the Workmen’s Compensation Ordinance 1922. This was replaced in 1947 by a more modern law based on the English Law of 1925. The main advantage of these laws was that through their interpretation the English innovations in the field of workers’ compensation were introduced in Israel.

The laws mentioned above were in force until 1 April 1954, when the Knesset passed the National Insurance Law 1954. This law authorized the National Insurance Institute to act according to the provisions of the law. The National Insurance Law was the first comprehensive social security law to include a wide range of National Insurance and statutory allowance programmes which were almost non-existent until the National Insurance Law came into effect.

The Law included three main branches of insurance benefits:

  • old age and survivors’ insurance
  • employment injury insurance
  • maternity insurance.


Through the years, the National Insurance Law has been amended many times. The main amendments connected with workers’ compensation are:

  • including the self-employed in the insurance system (1957)
  • “work accident” was expanded to include accidents occurring while walking or driving to work.


Types of coverage

Workers’ compensation insurance for employment injury is administered by the National Insurance Institute. The insurance covers both cash benefits and benefits in kind for work accidents. Employers who contribute to the insurance of the employees are no longer liable under the law of Torts. However, they may be liable in case of negligence. Benefits paid by the National Insurance are deducted from the compensation received by the employee.

Besides covering work injuries, the Institute covers occupational diseases. There is a list of occupational diseases attached as the second appendix to Regulations 44 and 45 of the Regulations of Work Accidents Insurance. The list is almost comprehensive and in effect covers 49 types of work-related diseases. The system of recognition for occupational diseases is a mixed system. This includes the occupational diseases listed, but other diseases of occupational origin can, subject to certain conditions, also be compensated.

According to the National Insurance Law, “occupational disease” means a disease defined by the Law (Chapter 85) as an occupational disease and contracted as a consequence of work or on behalf of his or her employment or, in the case of a self-employed person, as a consequence of his or her occupation.

Some compensation principles

The main role of the Workers’ Compensation Law is that the injured person is entitled to the benefits granted by the law, whether his or her employer contributed to the Institute or not, and the injured worker is eligible to file a claim for these benefits.

The Claims Officer of the Institute is empowered by the Board of the National Insurance to decide whether an injury or work-related disease claim is valid. If claimant is dissatisfied with the decision, he or she can file a suit with the Labour Court and have the right to appeal to the National Labour Court of Appeal.

The applicant in the proceedings in the labour courts, in accordance with professional decision, is granted free legal aid by the National Insurance Institute.

Mechanism for updating benefits

Employment Injury Benefits are adjusted from the 91st day in relation to the increase of the average wage on 1 January following the payment and during the year in relation to the wage increase received by workers due to inflation.

Injury Allowance (182 days) is taxable at source. Disability and long-term benefits are updated according to the cost of living increment and according to the changes that took place in the average wage as it was on 1 January. Disability and long-term benefits are not taxable.

When an insured person reaches entitlement to old-age pension (65 years for men, 60 for women), he or she can choose between the two forms of benefits.


All employers must contribute for their employees. Where an insured person is employed by several employers, each of them shall contribute as it he were the only employer. Self-employed and persons who are neither employees nor self-employed must contribute for themselves. The employer contributes to the National Insurance Institute. The average rate until 31 March 1970 ranged between 0.5 per cent and 3.0 per cent, and from 1 April 1971, between 0.7 and 4.0 per cent. From 1 October 1981 the minimum rate was 0.7 per cent and the maximum 2.4 per cent. From 1 July 1986, the standard rate of insurance contributions (0.7 per cent) has been determined without regard to the extent of risk in the various industries, as it was before 1986. As of 1 April 1987, the level of rates has been decreased due to low labour costs.

The rates of monthly contribution in the case of an employee shall be the percentage of the amount of his or her monthly income. In the case of other persons, the percentage shall be based on quarterly income.

The contributions are subject to maximum and minimum income of the insured. The maximum income for collection of contribution is calculated as four times the average wage for employees and for non-employees.

There are in the National Insurance Law certain exemptions from payment of contributions, such as an employee who received injury benefits for the time he or she received the benefits.


The National Insurance Law does not concern itself with work-related accident prevention. Paragraph 82 of the National Insurance Law refers to injuries caused by negligence of the insured person. Sanctions are applied in the form of non-payment of benefits where the insured is unable to work for less than ten days.

The National Insurance Institute contributes to associations in the field of accident prevention, such as the Institute of Occupational Safety and Hygiene.

The National Insurance Institute maintains a fund to support the financing of activities aimed at preventing work accidents, such as research and the development of experimental means broadly applicable in areas such as safety, engineering, medicine, and industrial chemistry and hygiene.



Foundations and Development

The statutory accident insurance system was introduced as an independent branch of social security by the accident insurance law of 1884 and has existed since 1885. It has the following legal responsibilities:

  • The accident insurance system, using all appropriate means, should assist in preventing work-related accidents and occupational diseases. In the future, this role should be expanded.
  • In the event of a workplace accident or the onset of an occupational illness, the system has the task of providing comprehensive compensation for injury or damages. In this capacity, the primary goal is to restore the health of the insured to the extent possible and to re-integrate the insured into occupational and social life (medical, occupational and social rehabilitation). Permanent health problems, furthermore, are to be compensated through annuity payments. If the case results in death, the survivors receive pensions and other monetary benefits.


In the course of its development, the system has been continually amended and expanded in many respects. This refers in particular to the enterprises covered (all-inclusive since 1942), the groups insured (e.g., the inclusion of schoolchildren, students and kindergarteners in 1971), the types of claims (1925 extension to include commuting accidents, accidents that occur while operating equipment at work, and occupational diseases) and indexation of monetary benefits (comprehensive since 1957). The continual improvement of measures, methods and practices for prevention and rehabilitation is also of great significance.

Structure and Organization

The implementation of accident insurance is currently conferred by law upon 110 accident insurance carriers (Berufgenossenshaften). These are organized in the public law, mostly as “corporations of public law”. Three domains are to be distinguished:

  • industrial accident insurance (including insurance for accidents at sea) with 35 carriers organized by industrial branch (e.g., mining, chemical, trade or health-care system)
  • agricultural accident insurance, with 21 regionally organized carriers
  • accident insurance for the public sector with 54 carriers that correspond for the most part to governmental divisions (federal, state and municipal groups, with separate funds for the postal service, railways and fire departments).


The most significant sector—industrial accident insurance—is given the most attention in the following discussion. As corporations of public law, the (Berufgenossenshaften) come under governmental administration and, as such, are part of the legal system . On the other hand, they are independent and self-governing in many respects. Both organs of self-administration, the assembly of representatives and the board of directors for each carrier are composed in equal proportion of employer and employee representatives chosen through elections. They make the decisions necessary to apply accident insurance within the legal framework. Whereas the preconditions for and scope of insurance benefits are regulated by law in individual cases, the accident insurance system preserves considerable self-administrative, decision-making latitude in setting premiums and especially in the area of prevention, which the self-administration fills out with concretizing and organizational regulations. The administrative organs of the (Berufgenossenshaften) also decide questions of organization, personnel and budget. Supervision by government authorities ensures that the decisions of the self-administration and administrative personnel are in accordance with the law.

Trends in Accident Rates and Finances

The number of work-related and commuting accidents decreased continuously over many years—until the increase due to the incorporation of the new federal state in 1991. The trend for the industrial accident insurance system can be summarized as follows: the accident rate—that is, the frequency of reportable work-related and commuting accidents per 1,000 full-time workers—decreased to less than half between 1960 and 1990. This positive trend can be even more clearly demonstrated in the case of severe accidents leading to compensation through annuities: a drop of nearly two-thirds in the accident rate. Fatal accidents fell by approximately three-quarters. Occupational diseases diverge from this trend and showed no uniform pattern of change during this time period. As new occupational diseases were progressively added to the list of occupational diseases, the number of cases of occupational diseases has increased, both with respect to prevention and rehabilitation.

The general decrease in the number and severity of accident insurance cases favourably affected costs. On the other hand, the following factors contributed to the increase in costs: indexing of monetary benefits, the general increase in health care costs, the expansion of persons insured, the broadening of insurance coverage—especially for occupational diseases—and the efforts to improve and intensify preventive and rehabilitative measures of the system. Altogether, the expenditures rose less than the salary base that is used to calculate the premiums. The average industrial accident insurance premium decreased from 1.51% in 1960 to 1.36% in 1990. As a result of the costs associated with German reunification, the average premium rose to 1.45% in 1994.

The distribution of costs for the three areas of responsibility (prevention, rehabilitation and financial compensation) have shifted in the following manner from 1960 to 1994:

  • The costs of prevention increased from 2.6 to 7.1%. This is attributable to the steady improvement, intensification and expansion of preventive measures of the system.
  • The portion of rehabilitation costs (including payments) rose from 20.4 to 31.2%. In this area, the increase of costs in the health-care industry cannot be absorbed by the decrease in accident frequency alone.
  • The portion of costs for annuities and pensions decreased from 77% to 61.7%. Despite indexation of annuities and pensions, this did not increase to the same extent as did the rehabilitation costs.


In other branches of the German social security system, the burden of premiums rose considerably during this time. On average, the cost of premiums for all branches of social insurance in the German Federal Republic was DM25.91 per DM100 wages in 1960; this figure rose to DM40.35 per DM100 paid by 1994. The portion of the average accident insurance premium to the premium burden of the total social insurance system decreased from 5.83% in 1960 to 3.59% in 1994. The proportion of accident insurance to the gross national product remained at approximately 0.5%. Thus only in the area of accident insurance could the economy be relieved to a certain extent of social taxes.

A decisive cause for this positive trend was the decrease in frequency and severity of accidents, as depicted above. In addition, the accident insurance system has succeeded, by further developing rehabilitation practice, in preventing or minimizing long-term disabilities in many cases. As a result, annuity cases have been almost constant despite the 40% increase in persons insured over that time period.

The decrease in the frequency of accidents can be traced to many causes and developments—the modernization of production methods (especially automation) and the structural shift from the production sector to the service and communications industries; the efforts at prevention undertaken by the accident insurance system have made a substantial contribution to this financial and humanitarian achievement.

Basic Principles and Features of the German Accident Insurance System

The system is supposed to provide comprehensive social security to individuals afflicted by work-related accidents or occupational diseases. It also relieves those who are responsible for such accidents and diseases in the plants from the burden of liability to the injured. The following basic principles can be traced to these twin objectives of the system, which have marked it since its inception:

The liability of employers for industrial injuries is replaced by a public-law obligation of the accident insurance system to provide benefits (“relief of employers’ liability”). Any civil damage suits by the insured against the business owner or other company employees are precluded.

Business owners alone make payments to the accident insurance system, as they bear responsibility for industrial hazards and are relieved of liability risks by the accident insurance system.

Insurance benefits, based on the principle of compensation for injury, substitute for civil liability claims against the employers.

Insurance benefits are provided independent of formal proof of the insurance relationship and independent of employer notification to the accident insurance carrier. A more reliable and effective safeguard is thereby provided for all persons legislatively covered by insurance protection.

The insurance benefits are provided, as a general principle, regardless of who is at fault and without suit by the entitled person. The employment relationship is thereby freed from disputes over the question of fault.

As an important supplement to the task of providing insurance benefits, the accident insurance system is responsible for preventing work-related accidents and occupational diseases. The system frees the employer from liability, but not from responsibility for organizing a safe and healthy work environment. The close connection of prevention with rehabilitation and financial compensation is of fundamental importance.

The basic organizational principles have already been discussed above (organized as a corporation of public law with the power of self-administration and structured according to industrial branch).

The relationship of the various areas of responsibility to one another is marked by two principles: The primary goal must be to keep the number of insurance cases as low as possible through appropriate preventive measures (“priority of prevention over compensation”). In the event of an insurance claim, the primary goal must be to rehabilitate the injured party medically, occupationally and socially to the extent possible. Only then shall any remaining disabilities be compensated in the form of monetary payments (“rehabilitation before annuity”).

The following sections will show how these basic principles operate within the specific areas of responsibility of the accident insurance system.


The task of prevention is based upon the following considerations: the accident insurance system, which bears the costs of work-related accidents and occupational diseases within the framework of rehabilitation and compensation, should first of all have the ability to prevent the occurrence of injuries insofar as possible. Employers should be aware that they remain responsible for health and safety in the workplace, even though their direct liability to the employees has been replaced by the accident insurance system. The connection between accident insurance and accident prevention should make clear to the parties involved—particularly the employers—that capital investment in workplace safety pays off, primarily in the humanitarian sense, by preventing human suffering, but also in an economic sense, through the reduction of accident insurance premiums and company costs resulting from injuries. Structuring the industrial accident insurance system by branches and involving the concerned parties within the framework of self-administration results in a high degree of practical preventive experience, as well as acceptance and motivation by those affected. This close connection between accident insurance and prevention distinguishes the German system from the systems of most other nations, which generally provide for the inspection of workplace safety by government officials. Such workplace safety authorities also exist in Germany in addition to the technical monitoring service of the accident insurance carriers. The two institutions complement and cooperate with one another. The responsibilities of the government supervisory authorities (factory inspection) go beyond those of the technical monitoring service of the accident insurance carriers (regulation of work hours, protection of especially high-risk groups such as juveniles and pregnant women, environmental protection).

The accident insurance system’s prevention mandate stipulates only the basic premises, allowing the self-administration of the carriers considerable latitude in the particulars—especially with respect to special features within specific branches that are applied to the individual plants or to the entire facility and by general regulations.

The most important aspects of the system’s conception of prevention include the following:

The (Berufgenossenshaften) are required to issue accident prevention instructions on specific danger areas. These instructions must be regarded as law by the employers and insured persons. Compliance with these instructions can be enforced by the carriers through sanctions (fines). These regulations are based on industrial experience and will be continually adjusted to the requirements of technical development.

Each carrier maintains its own specialized monitoring service, which advises and oversees the businesses. These are staffed by specially trained monitors—especially engineers and scientists—and are supported by experts in other disciplines according to the branch of industry being served. The authority of the monitoring services ranges from giving advice on binding regulations to closing down part of a plant in the case of an acute threat to health.

The carriers provide company doctors and safety specialists with advice, training, informational literature and work assistance. These internal work safety experts are important consultants for the monitoring services. This industry-specific cooperation strives to uncover accident dangers and work-related health hazards in advance, and to enable appropriate protective measures.

The monitoring services for the carriers check whether the employers comply with their obligation to engage company doctors and safety experts. Some trade associations maintain their own doctors and experts, to which their member companies can turn in cases where they have not arranged for their own.

The training and continuing education of the individuals assigned to implement occupational safety measures in the plants is mostly in the hands of the carriers. The training programmes are adapted to the needs of the individual branches of industry. They target and are differentiated according to the various levels of plant responsibility. Many accident insurance companies run their own training centres.

Accident insurance carriers address questions concerning workplace safety to the employers and managers, keeping them informed and motivated to improve prevention. Attention to small and middle-sized businesses has recently become the focus of preventive efforts.

The carriers’ technical monitoring services also advise the employees on health and safety risks in their workplaces. Cooperation with the workers’ councils, which represent the interests of the employees within the company, takes on greater significance in this connection. The employees should participate in organizing the working environment, and their experiences should be made use of. Practical solutions to safety problems can often be found by strengthening the participation of the employees. Improving safety can promote the employees’ motivation and job satisfaction, and have a positive effect on productivity.

The carriers’ technical monitoring services routinely inspect factories and investigate cases of accidents or occupational diseases. They then make many individual measurements corresponding to the dangers present, in order to work out necessary protective measures. The results of these measurements, of the analysis of the workplace and of the problems, together with knowledge derived from occupational medical care, are compiled using modern data-processing methods and are used throughout all plants to further promote prevention.

The carriers maintain specialized testing sites in which particular kinds of equipment and safety features are tested. Through this and through the advice of manufacturers and operators of technical equipment, the carriers obtain detailed information which they translate into the practical work of prevention in the plants and which they also introduce into national, European and international standards.

The (Berufgenossenshaften) have themselves conducted, initiated or financially promoted many need- and use-oriented research projects to advance knowledge in the field of safety and health protection.

In the interests of the employers as well as the employees, all the accident prevention work of the carriers aims to organize workplace safety and health measures as efficiently and economically as possible. Implementation strategies must also be practical. The effectiveness of preventive work is also monitored.

Scope of Insurance Protection

The insured

Employees who are working or in training are insured persons under the accident insurance system. Insurance protection is awarded regardless of age, sex, marital status, nationality, level of remuneration or length of employment. Insurance coverage is also guaranteed in the event that the business has not yet registered with the accident insurance carrier or has not paid premiums.

Homeworkers and persons who are active as employees in home industries are mandatorily covered, as are persons who receive rehabilitation measures from a social insurance carrier, and employers in some branches. All other employers can voluntarily insure themselves through the system.

In the agricultural accident insurance system, the employees, agricultural employers and employers’ spouses who work are obligatorily covered.

In the governmental accident insurance system, many groups are insured in addition to employees (but not the civil service and soldiers). These include students, schoolchildren and kindergarteners. Persons who are active in the interest of the public good and prisoners who work are also covered. A large portion of those insured by the government programme enjoy premium-free coverage, financed by federal, state and local governments.

The insurance cases

Insurance cases, or incidents, in the accident insurance system are workplace accidents and occupational diseases. Accidents which occur during the use or operation of equipment and commuting accidents also count as work-related accidents. The decisive criteria for insurance cases are as follows:

  • membership in an insured group
  • bodily injury resulting from a sudden work-related accident
  • exercise of an activity covered by insurance at the time of the accident or at the time of injury to health; covered activities are those closely connected to the employment relationship
  • an accident or an injury to health caused by an activity covered by insurance.


Fault on the part of the insured does not invalidate a claim. But if the only substantive causes of the accident are from the private sphere, then coverage will not apply—for example, an accident while an individual is under the influence of alcohol or as the result of a violent dispute. No insurance coverage is applicable to injuries which, though they occurred in the course of an insured activity, nonetheless arose as the result of a pre-existing health problem; this applies mostly to heart attacks and slipped disks.

Occupational diseases (those that are medically known to be caused by particular effects that certain groups are exposed to in their work to a higher degree than the general public) are included on an official list. If new information exists regarding an illness that does not appear on the list, the carriers can compensate the illness as an occupational illness.

Notification and statistical recording of insurance cases

In general, the benefits of accident insurance do not need to be applied for by the injured party, but are to be furnished at the initiative of the carriers. This presumes that cases are reported in some other way—employers, doctors and hospitals are obliged to inform carriers. This is the basis for a comprehensive statistical recording of occurrences of accidents and occupational diseases.


The system has the legal responsibility to provide comprehensive medical, occupational and social rehabilitation benefits upon the occurrence of an accident or the onset of an occupational disease. The objective of this mandate is, insofar as possible, to restore the health and the reintegration of the injured into work and society. Alongside the aforementioned principle of “rehabilitation before annuity”, the system provides all rehabilitation benefits of an accident insurance carrier “from one hand”. This guarantees a speedy and consistent rehabilitation programme, coordinated to the individual’s health, level of education and personal situation. The carrier is not confined to paying benefits and ensuring the care of the injured. Rather, the carrier optimizes the rehabilitation with specially qualified and equipped doctors and hospitals, through establishing carriers’ own clinics—especially for the care of severe burn victims and spinal cord and skull and brain injuries—as well as through observation, attendant care and, when necessary, corrective steering of the rehabilitation process. The following particulars apply:

Medical rehabilitation

The carriers must ensure that proper treatment begins as rapidly as possible after the incident. If necessary, this should include care from specialized physicians or occupational medical care. Physicians should participate in the treatment who are specialized due to training in accident medicine and have experience as surgeons or in orthopaedics, are equipped with a technical medical practice, and are prepared to fulfil certain duties with respect to the insurance carrier, particularly submitting forms and expert opinions.

After an incident occurs, injured persons should immediately go to a physician who is on contract with the carrier and who must prove the above-mentioned qualifications. They are empowered by the carrier to begin further treatment and to decide whether general treatment or special treatment—in cases of serious injuries—should be provided.

In the case of especially severe injury, the accident insurance system exacts the highest requirements in treating the injured person. Therefore, the insurance carriers authorize only specially qualified hospitals to undertake this treatment. These hospitals are subject to special guidelines and supervision.

The carriers use certain doctors to monitor and direct the treatment, who are required to supervise the treatment, to make reports to the carrier and, if necessary, to propose further rehabilitation measures.

The treatment and medical rehabilitation benefits are fully assumed by the accident insurance system (without copayment by the insured). This fulfils the injury compensation principle of the system.

Occupational rehabilitation

If medical rehabilitation alone cannot render injured persons capable of returning to their jobs, then the carrier must provide for occupational rehabilitation. The law provides for rehabilitation that conforms to the circumstances of each individual case (severity of disability, level of education, occupational qualifications and inclinations, age of the injured). The rehabilitation can result in measures specific to the plant, such as adapting the workplace to the disability; assistance in obtaining a position in the plant where the accident took place or in another plant; or financial support for the employer who is prepared to provide employment. Occupational training, including retraining for an entirely new occupation, is also covered.

As the system is responsible for providing medical as well as occupational rehabilitation, necessary occupational rehabilitation measures can be planned and started during the medical rehabilitation with the participation of the injured and the physicians. This task is performed by occupational counsellors—specially qualified and experienced employees of the carriers. They visit the severely injured while they are still hospitalized, attend to the insured persons, especially in searching out and selecting appropriate and promising rehabilitation measures, and stay with them until they are reintegrated into working life.

Social rehabilitation

Medical and occupational rehabilitation are essential preconditions to injured persons’ ability to resume living as much as possible as they did before the injury. Beyond this, however, it must also be assured that those suffering long-term health effects can not only resume work, but also social, family and cultural life as well. To this end, the carrier also provides social rehabilitation benefits; for example, vehicle assistance to promote mobility, handicapped sports to help promote health and participation in social life, household assistance or creating and equipping an apartment adapted for handicapped individuals.

Monetary benefits

During rehabilitation, the injured have a claim to continued payment of wages by the employer in the first period of the inability to work as a result of the incident (at least six weeks by the union contract). Then the carrier must provide “replacement pay” during the period of the medical rehabilitation. The disability payment corresponds, generally, to the net salary at the time of the incident—with deductions for the employees’ contribution to social security and unemployment insurance (at present almost 13 per cent). During occupational rehabilitation, a transitional wage replacement benefit is paid, which is somewhat less than the disability payment. These benefits are paid throughout the duration of the medical and occupational rehabilitation so that the insured and their families are financially secure. Continued payment of premiums to the other branches of the social security system prevents any gaps in insurance coverage.

Financial Compensation through Annuities

Insurance annuities

Insured persons receive annuities as compensation for remaining health problems from a work-related accident or occupational illness. These pensions are granted only at the close of the rehabilitation process and assume a definite decrease in earning capacity (generally 20%) for a minimum time period (beyond 13 weeks after the work-related accident). The annuities are calculated according to the degree of decrease in earning capacity and the annual earned income.

The principle of “abstract injury rating” applies in determining the degree of decrease in earning capacity. Accordingly, the loss of earning power on the general labour market and not the concrete loss of earnings (lost wages) caused by a work-related accident or occupational disease is taken into account. Measuring the decrease in earning capacity depends primarily on the severity of the health problem, which is in turn assessed by the expert opinion of a physician. This helps to minimize administrative costs and also keeps the burden on the insured and their employers to a minimum. In most cases, the abstract injury rating for annuities works out so that the insured are not in a worse overall economic position after the insurance incident than before. In many cases, indeed, a certain improvement of position results so that the annuities contribute in fact toward compensating for immaterial damages. The principles of the abstract injury rating and of “rehabilitation before annuity” work against the danger of an “annuity mentality” developing among the insured. The insured are motivated, despite any continuing health problems, to seek gainful employment.

The principle of the abstract injury rating is supplemented by factors of concrete damage assessment to ensure that appropriate compensation is made in all cases.

Annual earned income is the second basis upon which annuities are computed. By this is meant the sum of all wages and self-employed income an insured person earned during the year preceding the insurance incident. The annual earnings should reflect the standard of living that the insured had attained at the time of the workplace accident.

Under certain conditions, disability annuities can be fully or partially indemnified.

Survivors’ pensions and other death benefits

Widows, widowers and orphans—and under specific conditions also parents—have a claim for survivors’ pensions upon the death of insured individuals from work-related accidents and illnesses. The function of these pensions is to replace support lost through death. The computation is, as in the case of injury annuities, based upon the earned income. It is graduated according to the survivors’ need (especially widows with versus without children; children orphaned by one or both parents). Earned income and earned replacement income is taken into account in the case of survivors’ pensions, with the exception of orphans under 18 years of age. In the latter case the principle of loss replacement is applied: only those actually dependent upon support receive the benefits to the requisite and proportionate extent.

Along with survivors’ pensions, costs of conveyance and burial costs are guaranteed.

Widow and widower pensions are granted until remarriage; in the event of remarriage a settlement of two times the yearly annuity is paid.

Financing and Law on Premiums

There exist considerable differences among the three branches of the accident insurance system (industrial, agricultural and governmental) on financing and the law on premiums. The following discussion deals only with industrial accident insurance.

The costs of the industrial accident insurance system are financed almost exclusively by premiums from employers. Additional income received from indemnity claims against third parties (especially for traffic accidents), capital gains, late charges and fines is of relatively little significance. It should be emphasized that the industrial accident insurance system functions without financial assistance from the government. Revenues are raised and utilized solely to fulfil the legal obligation—attempting to turn a profit is forbidden.

Premiums for individual businesses are calculated based upon the employees’ wages that are subject to premium (or of the income from work or the insurance amount of the employer). The law on premiums takes particularly into account the occurrence of accidents and the attendant threat of accident in the branches of industry and individual businesses. Three levels are distinguished:

The first level of premium is conferred by collecting one or more branches of industry into an industrial insurance carrier as a common risk group. For example, more, and more severe, insurance incidents occur in the construction industry than in precision tool manufacture. Thus the premiums for a construction carrier are considerably higher on average than those for a carrier in precision tool manufacture.

At the second level, at the level of each individual carrier, the industrial branches included in this carrier—the bricklayers, roofers and janitors in the construction industry, for example—are classified according to the costs of accidents in the different risk groups. The general allocation of branches of industry into risk groups produces risk tables for each carrier. Each individual business is assessed by the carrier according to risk group on the basis of the risk tables. Different constituent parts of a business are assigned to various corresponding risk groups. The risk tables are actualized on the basis of five-year statistical surveys of accident frequency and costs. By means of the risk groups, the amount of the premiums for the individual branches of industry grouped within the same trade association are differentiated.

At the third step, the premiums are once again modified at the level of the individual enterprises. Here the criteria can be the number, severity and cost of the work-related accidents (excluding commuting accidents) over the last 1 to 3 business years. The insurance carrier can reduce the premium of an enterprise with a below-average incidence of accidents, or impose a premium surcharge in the case of an above-average incidence of accidents. The carriers are authorized to rule independently on the further detail (imposing surcharges or granting premium reductions, or combining the two).

Graduating the premiums for the various branches of industry and the individual enterprises according to accident trends is supposed to make the employers aware that the cost of accident insurance premiums also depends on efforts at—and the success of— prevention, and to spur efforts in this direction.

The accident insurance system is financed by a procedure of retroactive apportionment to cover costs. The amount to be apportioned is the excess expenditure over income, calculated retroactively for every budget year. The apportionment debit is divided among the individual member companies of the respective insurance carriers according to the premium computations (risk group of the company, total wages paid in that premium year and, if applicable, the premium surcharge or reduction). Naturally, ongoing costs must be financed in advance. This comes from collecting working funds and from pre-paid premiums. In order to compensate for long-term fluctuations in premiums, the accident insurance carriers must build reserve funds. These funds are preferentially invested in establishments that serve to fulfil the tasks of the accident insurance system—for example, training facilities or accident-care hospitals.

As accident insurance premiums cannot be calculated by the employer, the insurance carrier does the calculation and notifies the employer.

In the German accident insurance system, which is organized by industrial branch, structural changes in the economy can lead to an indefensibly heavy financial burden for some insurance carriers. This is especially the case for the coal mining industry. The number of working coal miners has declined substantially in the last decades, but the insurance carrier for mining must nonetheless pay annuities which date from a period when several times as many miners were employed. To remedy this extreme, no longer sustainable increase in the burden of premiums for that branch of industry, a method for sharing the burden among the various insurance carriers was introduced through legislation in 1968. The other insurance carriers are obliged to raise an additional apportionment to fill the financial gaps among those insurance carriers that have a right to equalization. Legislators thereby extended the fundamental notion of solidarity, which applies within each individual accident insurance carrier, to all industrial enterprises.



Wednesday, 23 February 2011 20:56

Workers' Compensation: Trends and Perspectives

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Workers’ compensation systems (WCSs) were created to provide payment for medical care and rehabilitation services for workers sustaining work-related injuries and impairments. They also provide income maintenance for the injured workers and their dependants during the period of disability. They were patterned after the systems maintained by guilds and provident associations in which members made contributions to funds which then were disbursed to members unable to work because they had been injured on the job. Once their usually slender savings were exhausted, the only alternative for workers who were not members of such systems was to rely on charity or to bring suit against the employer, alleging that the injury resulted from the latter’s wilful action or negligence. Such lawsuits were rarely successful for a variety of reasons, including:

  • the employee’s inability to command the requisite legal talent and his or her lack of resources compared to those of the employer
  • the difficulty of overcoming the employer’s defence that the accident causing the injury was either an “act of God” or the result of the worker’s own ineptitude or negligence, rather than that of the employer
  • the inability of the worker to wait out the often long time period required to adjudicate civil actions.


WCSs are “no-fault” systems requiring only that the worker file the claim as required and provide information demonstrating that the injury/disability was “work related” as defined in the legislation or regulations creating the WCSs in the particular jurisdiction. The requisite financial support is promptly available, supplied by funds accumulated by a government agency. These funds come from taxes on employers, from mandatory insurance mechanisms sustained by premiums paid by the employers, or from varying combinations of the two. The organization and operation of WCSs are described in detail in the previous chapter by Ison.

Despite gaps and deficiencies that have been addressed by legislative amendments and regulatory revisions over the past century, WCSs have worked fairly well as a social system providing for the needs of workers injured in the course of their employment. Their initial focus was on accidents (i.e., unexpected occurrences in the workplace or on the job), which are more easily identified than occupational diseases. The immediacy of the association between the occurrence and the injury makes the relationship to the workplace more or less simple to establish within the framework of the relevant laws and regulations. As a result, safety organizations have tried to develop, with more or less success, an epidemiology of accidents defining the kind of individuals, jobs and workplace circumstances associated with particular types of injuries. This led to the development of a sizeable safety industry devoted to studying various types of work-related injuries and identifying approaches to their prevention. Employers were constrained to adopt these preventive measures in the hope of escaping the burden of the costs of preventable accidents. These costs have been expressed in terms of workplace disruptions, temporary or permanent loss of productive workers, and escalating workers’ compensation taxes and/or insurance premiums paid by employers. An added inducement has been the passage in many countries of occupational safety and health legislation that enforces the requirement that employers adopt the appropriate accident prevention measures through the use of worksite inspections and various forms of penalties for lapses in compliance.

This arrangement has not worked very well, however, in the area of occupational disease. There, the relationship between the workplace hazard and a worker’s illness is often much more subtle and more complicated, reflecting the frequently long latency period between exposure and the initial signs and symptoms, and the confounding effects of influences such as the worker’s lifestyle and behaviour (e.g., cigarette smoking) and the coincidental development of non-work-related diseases. (The latter may, however, be influenced, aggravated or even precipitated by workplace exposures that under certain circumstances may bring them under the jurisdiction of a WCS.)

This article will focus initially on the validity of two related hypotheses:

  1. WCSs are able to develop preventive programmes based on adequate workplace risk assessments formulated through analysis of data derived from compensated cases of injuries and diseases; and
  2. WCSs are able to provide potent financial incentives (e.g., premium rating or bonus malus) to persuade employers to mount effective preventive programmes (Burger 1989).


In short, the nature and extent of risk on the job or in the workplace may be derived by analysis of workers’ compensation data using such variables as the presence of potentially noxious agents (chemical, physical, biological and so on), the characteristics of the workers involved, the circumstances at the time of the exposure (e.g., its nature, amount and duration), the pathophysiological effects on the worker, the extent and reversibility of the resulting disease or impairment, and the distribution of such cases among jobs, workplaces and industries. Identification and rating of the potential risks would lead to the development of programmes to eliminate or control them. Implementation of these programmes would lead to a reduction of work-related injuries and diseases, which would not only be beneficial to the workers, but would also reduce the direct and indirect financial burdens that otherwise would have to be borne by the employer.

We intend to show that the connections between compensated cases, risk evaluations, effective prevention efforts and lowering of employers’ financial burdens are not as simple as is usually believed. In addition, we will discuss a number of proposals offered by occupational physicians, lawyers and ergonomists to improve our knowledge of risks, enhance safety in the workplace and introduce more justice into WCSs.

Results of Studies

Value of the compensation insurers’ database

According to Léger and Macun (1990), the value of an accident database depends on the extent to which it allows safety performance to be measured, the causes of accidents to be identified, and the exposure to risk of subgroups within the working population to be determined. Accurate and effective accident statistics have great value for the design of effective accident prevention programmes by employers, labour organizations and government inspectors.

What data are compiled?

Statistics are limited to the accidents and illnesses defined by compensation laws and regulations and, therefore, recognized by WCSs. There is much variation among the cases so recognized within any given country or jurisdiction, between different countries and jurisdictions, and over time.

For example, in France the statistics compiled by the Institut national de recherche et de sécurité (INRS) are based on a list of occupational diseases coupled with a list of sectors at risk. In Switzerland, occupational diseases are categorized by the LAA (law on accident insurance) according to their association with conditions prevailing at the worksite. There, two categories are defined: in the first, a list of noxious agents accompanied by a list of diseases is provided; in the second, a list of diseases based on having demonstrated a strong possibility of causality between exposure and illness is provided.

Definitions of occupational accidents also vary. In Switzerland, for example, commuting accidents are not considered occupational, while all events occurring at the worksite, whether or not they are related to the work activity (e.g., burns resulting from cooking lunch), are encompassed by the definition of “occupational accidents”.

Accordingly, the number of cases recognized and tabulated in a particular jurisdiction is determined by the relevant legal definitions of accidents and diseases covered by the WCS. This may be illustrated by the Swiss statistics on occupational hearing loss, which was recognized as an occupational disease during the 1955-60 period. As soon as it was recognized, there was a marked increase in the number of reported cases, which produced a comparable increase in the total number of cases of occupational disease attributable to physical agents. Then, over the following years, the numbers of these cases tended to decrease. This did not mean that occupational hearing loss was any less of a problem. Since hearing loss develops slowly over time, once the initial backlog of cases hitherto not officially recognized had been recorded, the number of new cases tabulated each year reflected the constant association between noise exposure and the risk of hearing loss. Currently, we are witnessing another marked increase in the number of reported cases caused by physical agents, reflecting the recent official recognition of musculoskeletal disorders, commonly called “ergonomic disorders”, which include tenosynovitis, epicondylitis, rotator cuff problems, carpal tunnel syndrome and others.

Reporting of Cases

It is evident in all countries that many cases of accidents or diseases considered to be work-related are not reported, either deliberately or by omission. Reporting is generally the employer’s responsibility. However, as some authors have shown, it may be to the employers’ advantage not to report, thereby not only avoiding the administrative bother, but also preserving the reputation of the enterprise as a good place to work and preventing the accumulation of claims that might result in an increase in their workers’ compensation insurance premiums or taxes. This is particularly true for cases that do not involve any lost work time as well as those that are treated by an employee health service at the worksite (Brody, Letourneau and Poirier 1990).

It is the physician’s responsibility to recognize and report cases of occupational injury and disease and to notify the patient of his or her rights to compensation. However, some cases are not reported because they are treated by general practitioners who do not recognize the work-related nature of a health problem. (A knowledge of occupational and legal aspects of health care should be an integral element of medical education. International organizations such as the ILO should encourage the inclusion of such subjects in undergraduate as well as postgraduate training for all health professionals.) Even when they do make the connection, some physicians are reluctant to accept the burden of the necessary paperwork and the risk of being required to testify in administrative procedures or hearings if the worker’s claim for compensation is contested. In some jurisdictions, the fact that statutory or scheduled fees for treating workers’ compensation cases may be lower than the physician’s customary charges may be another disincentive to proper reporting.

The reporting of cases also depends on how much workers know about their rights and the WCS under which they are covered. Walters and Haines (1988), for example, surveyed a sample of 311 unionized and non-unionized workers in a highly industrialized area of Ontario, Canada, to assess their use and knowledge of the “internal responsibility system”. This was created by local legislation to encourage employees and employers to resolve health and safety problems at the plant level. While 85% felt that their working conditions might harm their health, only one-fifth reported time lost from their jobs due to a work-related health problem. Thus, despite beliefs about the damaging effects of their work on their health, only relatively few used the rights and resources provided in the legislation. Their descriptions of their refusals to work and their worries about the health effects of their work contained very few references to the “internal responsibility system” provided by the legislation. In fact, the main contact they reported was with their supervisor rather than the designated health and safety representatives.

Awareness of the legislation was greater among unionized workers, the researchers found, and was more often associated with taking actions relating to occupational health and safety (Walters and Haines 1988).

On the other hand, some workers make claims for compensation even if the injury or disease is not related to their work, or continue to claim benefits even when they are capable of returning to work. Some studies have shown that liberal compensation coverage may even be an incentive for filing claims. According to Walsh and Dumitru (1988), in fact, “improved benefits may result in additional claim filing and injuries”. These authors, using the example of back injuries (which constitute 25% of workers’ compensation claims in the United States) note that “workers are more demanding of time off for injury when compensation is comparable to earned wages”, adding that “the system of disability compensation in the United States does increase the frequency of certain types of disability claims and contributes to delayed recovery from LBP” and that “compensation factors may delay recovery, prolong symptoms, and reinforce sick role behaviour”.

Similar observations were made by Judd and Burrows (1986), based on a study of a representative sample of Australian workers in which, in the course of one year, 59% “have been away from work for more than two months, and 38% for longer than six months.” It is suggested that “the medical and legal services may result in this high rate of prolonged invalidism” and that “recovery appears to be against the victim’s best interest, at least for the settlement of compensation”.

Admissibility of Cases

As noted above, national statistics reflect changes in the admissibility of types of cases. Examples include adding a new disease to the list of compensable diseases, as in the case of hearing loss in Switzerland; extending coverage to new types of workers, as in the changes in wage scale limits in South Africa; and extending coverage to new types of businesses.

Unlike accidents, occupational diseases are not readily compensated. A study of a large sample of workers who had lost at least one month off the job was conducted in francophone Switzerland. It confirmed that accidents were largely accepted as work-related and compensated promptly, but only a small percentage of illnesses were accepted (Rey and Bousquet 1995). The end result in cases of illness is that it is the patients’ health insurance rather than the WCS that pays the medical charges. This does not increase the cost to the employers (Rey and Bousquet 1995; Burger 1989). (It should be noted that where, as in the United States, the employer also bears the cost of general health insurance, the cost may be even greater since the fees allowed by WCSs are often lower than those charged by private health-care providers.)

Yassi (1983) wrote a report on a lecture given by Prof. Weiler, in Toronto. Some of Weiler’s remarks, quoted by Yassi, are worth mentioning here:

the Workmen’s Compensation Act worked fairly well in compensating for disability due to accidents—the same cannot be said for occupational diseases—Whereas, even in the most difficult cases of injury due to accident, the cheque was in the mail within a month or so, the average time for adjudicating cancer claims is about seven months (idem for respiratory disease claims). Only a small percentage of claims for injuries is rejected (around 2 per cent); in contrast the rejection rate for claims for serious diseases is well over 50 per cent.

Particularly striking is the under-reporting of occupational cancer cases: “Less than 15 per cent of the estimated number of occupational cancers are reported to the Board.”

The necessity of demonstrating a causal relationship between a disease and the job (e.g., a recognized toxic agent, or a disease on the accepted list) is a major obstacle for workers trying to receive compensation. Currently in most industrialized countries, the WCSs compensate less than 10% of all occupational disease cases, and most of these are relatively minor illnesses such as dermatitis. And in most of the 10% that are ultimately compensated, the basic question of compensability first had to be litigated (Burger 1989).

Part of the problem is that the legislation in the particular jurisdiction creates what have been called “artificial barriers” to compensation for occupational diseases. These include, for example, a requirement that to be compensable a disease must be peculiar to the workplace and not “an ordinary disease of life”, that it be listed on a specific schedule of diseases, that it not be an infectious disease, or that disease claims must be filed within a restrictive period starting with the time of exposure rather than the time the presence of the disease is recognized (Burger 1989).

Another deterrent has been the growing awareness that many occupational diseases are multifactorial in origin. This sometimes makes it difficult to pinpoint an occupational exposure as the cause of the disease or, conversely, allows those who would deny the worker’s claim to hold that non-occupational factors were responsible. The difficulty of proving an exclusive workplace cause-and-effect relationship has placed an often overwhelming burden of proof on the disabled worker (Burger 1989).

Mallino (1989), discussing scientific aspects of artificial barriers toward compensation, states that

Most of these artificial barriers have little or no relation to modern medical science which has concluded that most occupational diseases are multicausal in nature and have relatively long latency periods from the time of initial exposure to the actual manifestation of disease.

In most cases of traumatic injury or death, the cause and effect relation is clear: a worker loses a hand in a stamping machine, falls from a scaffold, or is killed in a grain elevator explosion.

For many of these diseases, such as work-related cancers, it is often difficult, if not impossible, to determine a specific cause and then link it specifically to a particular workplace exposure or set of exposures.

Moreover, risk-facing equality does not exist, and it is highly problematical to assess the degree and nature of occupational hazard solely on the basis of compensated cases. Past compensation experience in individual sectors of employment usually forms the basis on which insurers rate the risks associated with employment and calculate the premiums to be assessed on the employers. This provides little incentive for preventive programmes, even though industries such as mining or forestry are known to be dangerous.

More fruitful, however, is the notion discussed by Morabia (1984) of “homogeneous groups”. Grouping similar workers across sectors demonstrates quite clearly that risk is more related to skill level than to the type of industry, as such.

Inequalities among Workers Facing Job Hazards

Risk inequality is measured by several variables:

Effect of skill level

Differences in risk exposure between skilled and unskilled workers are independent of the company’s type of production and are not limited just to the type of workplace and exposure to toxic agents (Rey and Bousquet 1995). In Canada, for example, Laflamme and Arsenault (1984) found that the frequency of accidents among different categories of production workers is not randomly distributed. Less skilled, manual labourers—a minority of the workforce—suffered the highest proportion of accidents.

Moreover, injuries were not distributed by chance either; in unskilled piece-paid workers, the frequency of lumbar injuries is higher than in other groups, as well as other locations. Unskilled workers, in the type of work organization described by Laflamme and Arsenault (1984), concentrated risk factors. Differences in risk exposure with other groups of workers were exacerbated by what appeared to be an implicit “political” attitude in which preventive measures were more likely to be focused on the skilled workers, an organizational arrangement that was inherently discriminatory to the detriment of the unskilled workers, among whom the risks were concentrated.

Effect of work experience

The most vulnerable workers are those with the least experience on the job, be they newly hired or subject to frequent job changes. For example, data from INRS and CNAM (Conservatoire national des arts et métiers) in France show that temporary workers have 2.5 times the accident rate of permanent employees. This difference is attributed to their lack of basic training, less experience in the particular job, and inadequate preparation for it. In fact, the researchers note, the temporary workers represent predominantly a population of young, inexperienced workers who are exposed to high risks in workplaces without effective preventive programmes.

Moreover, accidents happen most frequently during the first month of employment (François and Liévin 1993). The US Navy found that the highest incidence of injury among shore-based personnel occurred during the first few weeks on the job. Approximately 35% of all hospitalizations occurred during the first month of a new job assignment; this frequency then decreased sharply and continued to decline as time on the assignment increased. A similar tendency was displayed by personnel on sea duty, but the rates were lower, presumably reflecting more time in the navy (Helmkamp and Bone 1987). The authors compared their data to that of a 1979 report from the US Bureau of Labor Statistics of the National Safety Council and found similar results. Moreover, they noted that the above-mentioned phenomenon varies only slightly with increasing age. While young workers are at highest risk for accidents for reasons noted above, the “new-to-the-job” factor remains important at all ages.

Effects of type of wage scheme

The way workers are paid may influence the frequency of accidents. In his critical review of publications on incentive wages, Berthelette (1982) notes that the piece-work method of pay is associated with a higher risk of accidents. In part, this can be explained by the incentive to “cut corners” and ignore job risks, by overwork, and the accumulation of fatigue. This negative effect of the piece-work incentive was also recognized by Laflamme and Arsenault (1984) in the furniture industry, as well as by Stonecipher and Hyner (1993) in other industrial activities.

The “healthy worker effect” (HWE)

There is ample evidence of the beneficial health effects of work and the negative health impact of unemployment. The HWE, however, does not connote that work is good for health. Rather it signifies that the working population is healthier than the population as a whole. This reflects the difficulty of those who are chronically ill, severely disabled or too old in obtaining and holding jobs, and the fact that those who are least able to cope with job risks are soon forced to abandon their jobs, leaving a workforce of the healthiest and most fit workers.

The HWE is defined by epidemiologists as a submortality (or, also, as a submorbidity) of workers compared to the mortality or morbidity of the whole population. For epidemiologists who use firms as a field for studying a disease, such an effect needs to be minimized. In his article on HWE, Choi (1992) considers not only the reasons, but also the methods, for decreeing this selection bias.

From the point of view of ergonomists, non-occupational factors, such as lower financial resources and family problems, may also enter into the picture, in addition to occupational factors such as lack of professional incentives and fear of not measuring up to one’s job requirements. If a worker voluntarily leaves a job very quickly—a few days or weeks after starting—the possibility that age has rendered the worker less capable of facing the demands of the job must be considered.

For example, the diminishing incidence of low-back pain (LBP) with age does not imply that older workers are necessarily more resistant to back pain. Instead, it suggests that those with a predisposition to backache (e.g., those with anatomical defects, poor musculature and/or poor physical condition) have discovered that bad backs are not compatible with heavy lifting and have migrated to other types of work (Abenhaim and Suissa 1987).

In the study by Abenhaim and Suissa, data were obtained from the Workmen’s Compensation Board of Quebec from a sampling of 2,532 workers who had lost at least one day of work due to back pain. The 74% of compensated workers who were absent from work less than one month accounted for 11.1% of lost workdays, while the 7.4% of workers who were absent more than six months accounted for 68.2% of the lost workdays. The latter group of workers (0.1% of the workforce) were responsible for 73.2% of the medical costs and 76% of compensation and indemnity payments (a total amount of 125 million dollars (1981). Each of these cost approximately 45,000 Canadian dollars. The high incidence rate found in men (85% of the cases) could be explained by the presence of a larger population of men in those tasks with a greater probability of back injury. Other explanations are less likely, such as a higher vulnerability of men or a greater proportion of men filing compensation claims. Abenhaim and Suissa state:

The increase-decrease pattern of back pain with age is most probably due to the healthy worker effect; workers would be more likely found in back-threatening tasks before age 45 years and would quit these jobs after they become older... The results of the study are at variance with the belief in industrialized countries that the major portion of this type of medical expense is due to ‘uncontrolled’ multiple periods of absence from work due to back pain with ‘no objective signs.’ The more socially significant cases are among those with long duration of absence and heavy medical assistance. Prevention and occupational health and safety policies should bear this finding in mind.

In brief, numerous factors not taken into account in tabulating the statistics of occupational injuries and diseases can modify the fundamental underpinnings of the data and completely transform the conclusions reached by workers’ compensation officials and others. This has particular relevance for those using these data as the basis for designing programmes to control particular hazards and ranking the urgency of their implementation.

Life and work events; stress

Stress is a major factor in the causation of work-related injuries and diseases. Stress in the workplace, whether arising out of the job or brought to the workplace from life at home and/or in the community, can affect behaviour, judgement, physical capabilities and coordination, leading to accidents and injuries, and there is growing evidence that it may affect the immune system, increasing the susceptibility to disease. In addition, stress has a significant influence on the response to rehabilitation therapy as well as on the extent and duration of any residual disability.

In attempting to account for the increased rate of accidents during the weeks immediately following a transfer from shore duty to sea and vice versa, Helmkamp and Bone (1987) suggested that the stress created by the transition and the changes in patterns of living may have been a contributing factor. Similarly, Von Allmen and Ramaciotti (1993) noted the influence of both job-related and off-the-job psychosocial factors in the development of chronic back problems.

In a 27-month prospective study among air traffic controllers, levels of social stress were dramatically related to the occurrence of accidents. The 25% of the study group of 100 workers who reported high levels of stress developed a total morbidity rate 69% greater than that of the workers reporting low stress levels, and an 80% greater chance of incurring an injury (Niemcryk et al. 1987).

It is not surprising, therefore, that at least in the United States there has been a proliferation of workers’ compensation claims attributing disability to alleged occupation stress. Even though such claims are still not allowed in many jurisdictions, their rate of increase has probably been exceeded only by the surge of recent claims for repetitive injuries such as carpal tunnel syndrome, and other ergonomic disorders.

Claims based on alleged stress offer another illustration of the “artificial barriers” to compensation noted above. For example, some of the jurisdictions in the United States (mainly the individual states) do not accept any claims based on stress: some will accept them only if the stressor is a sudden, discrete or frightening or shocking event, and some require the stress to be “unusual” (i.e., in excess of the stress of everyday life or employment). Some jurisdictions allow stress claims to be adjudicated on their merits, while there remain some where neither statutes or case-law have yet established sufficient consistency to constitute a guideline. Accordingly, it appears, the worker’s chance of success with a claim based on stress is as much a factor of where the claim is filed and adjudicated as the merits of the claim (Warshaw 1988).

Perception of risk

Before employers decide to improve working conditions, and before workers choose to work more safely, they must be convinced that there is a risk to be guarded against. This must be personally perceived; “textbook knowledge” is not very persuasive. For example, non-unionized workers are less likely to complain about potential work hazards because they tend to be less well informed about them (Walters and Haines 1988).

Risk-taking, the willingness of individuals to accept danger in the workplace, depends to a large extent on the culture of the organization. One can find a blasé attitude with risk-taking encouraged (Dejours 1993), or a more prudent approach (Helmkamp and Bone 1987).

Where there is a low accident rate and workers have never witnessed a serious accident, and especially where there is no union to sensitize workers to latent hazards, there may in effect be a denial of risk. On the other hand, where workers are aware of risks of serious injuries or even fatalities, they may demand supplemental hazard pay (Cousineau, Lacroix and Girard 1989). Deliberate risk-taking may, therefore, be stimulated by the desire or need for the extra pay.

Attitudes toward risk-taking on the job generally reflect the workers’ attitudes toward prevention in their personal lives. Stonecipher and Hyner (1993) noted that salaried employees had significantly higher levels of participation in health screening programmes and pursuing a healthy lifestyle compared to wage (paid on an hourly basis) workers, who tended to be less well educated and lower paid. Thus, low-skilled, low-wage workers who, as noted above, are prone to higher rates of accidents and injuries are also more likely to indulge in excessive use of tobacco and alcohol, have poor dietary habits and be less likely to take advantage of preventive health services. As a result, they appear to be in double jeopardy.

Organizational culture and risk levels in the enterprise

Characteristics of the organizational culture in the enterprise may influence the perception of risks in the workplace and, therefore, actions to control them. These include:

Size of the enterprise

Risks of occupational injuries and diseases are inversely related to the size of the enterprise. In Switzerland, for example, the smallest enterprises outside of the high-tech industries (up to ten employees) account for a very high percentage of the cases of occupational diseases recognized by the CNA (Caisse nationale suisse d’assurance en cas d’accidents—Swiss national accident insurer). In contrast to the larger enterprises, these small shops have less of a chance of recruiting the best trained, the most experienced and, from the standpoint of their health, the hardiest workers. Their owners and managers are less likely to be knowledgeable about workplace hazards and to have the time and financial resources to address them. They are inspected much more rarely and have greater difficulty than their larger counterparts in obtaining access to the technical assistance and specialist services they may need (Gressot and Rey 1982).

Rejection of responsibility

In Switzerland the employer is responsible for the safety of the worker and the worker is required to abide by the safety systems established at work. Unfortunately, the law and reality are not the same. A study of Swiss workplaces with 100 or more employees disclosed a tendency for each of the involved parties to deny responsibility for the accident and blame the other. Thus, employers pointed to the employee’s alcoholism or disregard of safety rules as the culprit, while the employees blamed workplace deficiencies and ineffective management. In addition, the industries rated most dangerous by the insurance companies tend to understate the risks (Rey et al. 1984).

Prevention of compensation cases reduces employers’ costs

In theory, the WCS is designed to reward employers who successfully mount effective prevention programmes and lower the frequency and severity of injuries and illnesses by reducing the workers’ compensation taxes or premiums levied on them. But this hypothesis is often not validated in practice. The costs of the prevention programmes may exceed the premium reduction, particularly when the premiums are based on a percentage of total payroll during a period when there have been significant wage increases. Further, the reduction may be meaningful only in very large organizations where premiums rates may be based on the experience of the individual company, in contrast to smaller organizations who pay “manual” rates that reflect the experience of a group of companies in a particular industry or geographic area. In the latter case, a single company’s improvement may be more than offset by the unfavourable experience of other companies in the group.

There is also the reality that although the number and severity of accidents and injuries may be reduced, the premiums are driven up by the escalating costs of medical care and by more generous payments for disability, particularly in the industrialized countries.

Theoretically—and this often happens—the costs of the prevention programme are more than recouped by continuation of the premium “rebates” as the improved compensation experience persists, and by avoidance of the indirect costs of work-related injuries and illnesses. The latter may be expressed in terms of workplace disruptions, absenteeism and lost production; these may be greater than the costs of workers’ compensation.

Attitudes of employers and managers

Most employers are genuinely concerned about the health and welfare of their employees and, in many larger organizations, this concern is often explicitly stated in formal policy statements. Too many managers, however, are much more concerned about their own status with respect to pay increases or bonuses and advancement within the organization. Competition among segments of the organization for awards and other recognition for holding down the number of injuries and illness often leads to concealment of accidents and denial of workers’ claims for compensation.

An important factor is that while preventive programmes require an upfront expenditure of money and other resources, notably staff time and effort and consultants’ fees, their payoff is often delayed or masked by unrelated rare events. This becomes a significant barrier when the enterprise is financially stretched and forced to restrain expenditures or even reduce them. The delayed payoff may also be critical for plant managers and other executives whose performance is judged by the “bottom line” at the end of the fiscal year or other accounting period. Such an executive may readily be tempted to defer investing in a safety programme until he or she has been promoted to a higher position in the organization, leaving this problem for a successor.

Labour-management collaboration

Labour-management collaboration is critical to the success of programmes to prevent work-related injuries and illnesses. Ideally, a joint labour-management committee will be created to identify problems, design programmes to address them and monitor their implementation.

Too often, however, such collaboration is prohibited or at least made difficult when relations between the employer and the union become inordinately adversarial. For example, employers sometimes resist union “intrusions” into workplace operations and activities and resent the union’s militancy in sensitizing their members to potential workplace hazards and encouraging them to pursue workers’ compensation claims on what the employer may regard as insufficient or inappropriate grounds. Unions, on the other hand, often feel compelled to be aggressive in advancing the interests of their members against what they regard as the lack of interest of the employers.

Suggested Reforms

Reform of the WCSs is not a simple matter. It necessarily involves a number of parties (e.g., workers and their representatives, owners of enterprises and employers, government agencies, compensation insurance carriers, legislators) each of whom has vested interests to protect. However, the high stakes involved—the health, well-being and productivity of workers and their dependants—make WCS reform a matter of more than a little urgency. Included among some of the reforms that have been suggested are the following:

Making statistics and their analysis reliable and compatible

There is currently an effort underway to make statistics internationally comparable. A single formula for European countries is one laudable example. There are directives that correspond to current practices, looking at the frequency or severity of cases by industrial sector, by physical or chemical agent, or by the conditions surrounding the accident.

The formula is not a radical departure from current practices such as those of the Swiss CNA, and thus one can hardly expect that the biases discussed above will be avoided. In Switzerland, however, the authorities have reacted favourably to the new requirements for the involvement of safety and health specialists at the enterprise level, particularly to the idea that information on risk should not rest solely on insurance company statistics, but rather should also have access to precise epidemiological studies.

It appears that in Europe, the member countries of the community have decided to adhere to the principle of a uniform formula for data collection. In the United States, however, a recent study showed that the creation of a data bank on insured cases does not have the same chance of success, according to Johnson and Schmieden (1992), despite the size of the insured pool and the expenses incurred by the insurance companies.

In the United States, workers’ compensation is big business, with almost 91.3 million workers covered in 1988, and nearly $34 billion paid out in benefits to workers at a cost to employers of over $43 billion for that year. Currently, workers’ compensation costs are increasing more rapidly than other health-care costs, a fact that seems to have escaped the notice of many employers who have been focusing on the escalation of employee health insurance costs, which many assume is partially or totally responsible. A unified database seems much less likely to be developed in the United States, in contrast to the European countries. Nevertheless, it has been suggested that, as a starting point, making the currently available workers’ compensation data more accessible to those who should be interested in it by having health science resource centres and libraries collect and disseminate it would be useful (Johnson and Schmieden 1992). Their survey on 340 relevant libraries in the United States and in Canada indicates that only about half of them do provide information services on this topic; only 10% foresaw a future need for a collection in this field, while most respondents indicated no need or did not answer. With increasing concern about the rapid rise in workers’ compensation costs, it seems reasonable to expect that employers, insurers and their consultants would press for the development of such data resources.

It should be noted that this is not the first time that such an initiative has been undertaken in North America. Following the 1981 report of the Joint Federation-Provincial Inquiry Commission into Safety in Mines and Mining Plants in Ontario, it was recommended that a database be developed that would:

  • formulate clear and unambiguous definitions of which accidents are to be included
  • profile each reportable accident (how, when, where, why, severity of injury and so on) and each worker (age, sex, type of job, length of service and so on)
  • provide background data on the characteristics of the work force as a whole (e.g., skill levels, training and experience) along with data on production levels, hours of work and so on.


In interpreting the available statistics, indices defined in thresholds of time off from work should be emphasized and greater weight given to indices that are less amenable to social and economic influences (Léger and Macun 1990).

Separating compensation from prevention

It has been contended that the purpose of the WCSs should be limited to the collection and distribution of funds for the workers’ compensation benefits prescribed in the relevant legislation, while prevention of workers’ injuries and diseases is an extraneous matter that should be relegated elsewhere.

Mikaelsson and Lister (1991), for example, suggest that abuse of the WCS in Sweden makes the validity of the Swedish accident and illness data very questionable and not at all useful as a basis for designing preventive programmes. The Swedish WCS, they contend, invites multiple appeals and permits arbitrariness. Its costs have been rising rapidly largely because compensation is often granted without substantial evidence of a relationship of the injury or disease to the job, while the rules of evidence discourage a meaningful search for the actual cause.

Because the issue of causation is obscured or bypassed entirely, the Swedish data present a misleading picture of occupational injuries and diseases. The reported incidence of some diseases may be inflated (e.g., low-back pain) while causes of other disease may be entirely overlooked.

Let us stress here that the new Swedish law on compensation, under the influence of the multiplication of claims, particularly for low-back pain (LBP), is going backward. As it now operates, the Swedish WCS offers no incentives for employers to identify and eliminate the actual causes of occupational diseases and injuries. The meaningful investigation of the nature, extent and control of occupational hazards could be assigned to other agencies designated under other provisions of Swedish law (see “Country Case Study: Sweden” on page 26.26).

Burger (1989) goes one step further, suggesting that all occupational injuries and illness should be compensated without any preconditions and that the WCSs be subsumed in the general social insurance programme. On the other hand, he states, if the test of causal relationship is to be retained for coverage by the WCSs, that test should be performed, rigorously observing all the traditional criteria for the validity and quality of medical-scientific information.

Merge compensation medicine with general health care

In some jurisdictions, treatment of individuals with compensable injuries and illness is restricted to physicians and other health professionals who have been credentialed as having the knowledge and skill to deal with such problems. This, it is hoped, will ensure the quality of their care.

In some instances, this has had just the reverse effect. The great majority of workers’ compensation injuries are relatively minor and require little care beyond first aid, presenting little in the way of interesting challenges to the physician. In jurisdictions where statutory fees established for the care of such cases are lower than those that are customary in the area, there is an economic incentive to increase the number and extent of treatments. For example, when caring for a cut or laceration in New York State in the United States, the Workers’ Compensation Fee Schedule allows a supplementary fee of $1 for each suture up to a maximum of ten; thus, one sees wounds closed with ten sutures regardless of their length and even when adhesive “butterflies” might suffice. Also, to be convenient to workplaces, physicians’ offices and polyclinics treating workers’ compensation cases are often located in industrial districts that are generally not among the most prepossessing parts of town. As a result of such factors, compensation medicine often does not rank very high among the fields of medical practice.

Further, from another perspective, in areas where there are shortages of medical facilities and personnel, occupational injuries and diseases must perforce be treated in the nearest available physician’s office or polyclinic, where sophistication in the care of work-related health problems may be minimal. This is a particular problem in non-urban, non-industrialized areas and for enterprises too small to have their own employee health service.

At the opposite pole from those who would separate prevention from compensation are those who would give it greater emphasis as part of workers’ compensation. This is particularly true for Germany. This is also seen in Switzerland since the new law on accidents and occupational diseases (LAA) went into effect in 1984 covering the entire field of work safety. The federal commission of coordination (CFST) was then created with representatives of the confederation and cantons and representatives of the CNA and of other insurance carriers, public and private.

The CFST is responsible, among other things, for formulating technical regulations in the form of directives for the prevention of accidents and occupational diseases. It is also responsible for financing the workplace safety enforcement authorities (e.g., by reimbursements to the cantons) for the costs of workplace inspection.

The CNA is the major insurance carrier for occupational injuries and diseases and, in the field of workplace safety, monitors the application of rules of prevention for occupational accidents in approximately 60,000 enterprises—those that, in principle, expose the workers to the most serious dangers (e.g., those that produce or use explosives, use the greatest quantities of solvents, chemical companies). The CNA also issues directives on concentration limits for toxic substances on the job, limits that are supposed to be respected by the employers.

As the agency that applies the LAA and its regulations, the CNA must inform the employers and the workers of their respective responsibilities. The employer is required to take all steps and measures required by the regulation on accident and occupational disease prevention (OPA). The worker is required to follow the instructions of the employer on the question of workplace safety.

During factory visits to verify compliance with regulations carried out by the CNA (or by other, especially cantonal, monitoring bodies) the employer is required to permit inspectors access to all premises and job sites. If a violation is found, the CNA draws the employer’s attention to it and sets a deadline by which the situation must be corrected. If a warning is not heeded, the CNA orders the necessary measures by way of executory decision. In case of non-compliance, the company can be placed in a higher risk category, warranting an increased premium. The insurer (CNA or other insurer) must make the decision to increase the premium immediately. Furthermore, the executory body (in particular, the CNA) takes coercive measures, with the assistance of the cantonal authorities, if needed.

The CNA’s technical services participate in the factory visits, but are also available to the employers to offer advice on safety matters.

In the field of occupational diseases, the employer has to see that the workers to whom the regulations apply undergo preventative medical examinations, performed by the nearest doctor, or by the CNA’s own medical service. The CNA determines the content of the preventative medical examination and ultimately decides on a worker’s aptitude to fill the job.

All the technical and medical measures that the employer must take to fulfil his legal obligations are at his expense. Financing the inspection and administrative activity of the CFST and its executory bodies is ensured by the supplementary premium.

The CNA and the other insurers are required to furnish to the CFST the information that allows it to form the basis necessary for its action, especially establishing the accident and occupational disease statistics. When a new regulation was promulgated on company doctors and other safety specialists, the federal social insurance office (OFAS) issued report number 92.023, 1992. This report says that risk analysis cannot rest solely on accident and occupational disease statistics available to authorities (known case), but equally on epidemiological research, carried out in Switzerland or abroad.

Finally, the CFST is responsible for promoting information and instruction on job safety at every level. In Geneva, workplace inspection is organized with the CFST and the CNA, and with the support of the university scientists, conferences, practical safety courses for businesses in Geneva or other groups of interested persons. A tripartite commission with representatives from government, the employers and the workers is behind this initiative, which is largely subsidized by the canton.

Abandoning the one-dimensional causal relationship in favour of a multifactorial view of the links connecting workplace risk and disease

In most cases of occupational accidents causing injury or death, there is a clear-cut and direct causal relationship between the incident and the trauma. Such an “iron rule” is hard to impose when confronted by occupational diseases, which are generally multicausal in origin. Causality is further complicated by the long latency period from the initial exposure to the first recognizable manifestations of the disease. For many occupational diseases, such as work-related cancer, it is difficult if not impossible to identify a specific cause and then link it to a particular workplace exposure or set of exposures. Accordingly, rather than pursuing the workers’ compensation route, many workers with these diseases turn to the general health-care system (in the United States, for example, private health insurance—or Medicare if they are old enough, Medicaid if they are poor enough) and to the public welfare system when financial support is needed.

As a result, “employers for all practical purposes are paying little or nothing for occupational disease and, in fact, are being subsidized by the public welfare system and workers themselves” (Mallino 1989).

The results of a study conducted in francophone Switzerland (Rey and Bousquet 1995; Von Allmen and Ramaciotti 1993) came to the same conclusion. The medical insurance carriers are thus required to assume the costs, at the expense of the insured and of the taxpayer, for health hazards clearly linked to workplace activity, such as certain back pains among workers who carry heavy loads.

As the employers do not feel constrained to correct the problems of jobs that are nevertheless responsible for these health hazards, this anomaly is also unhealthy from the perspective of prevention, which should be based on the existence of cases registered by the workers’ compensation system.

To resolve this type of problem, Mallino proposes an approach that requires only a demonstration that the occupational exposure was a contributing factor to the disease rather than the immediate, direct and only cause. Such an approach is much more consistent with modern medical science, which has established the multicausality of many diseases.

Using a set of presumptions based on the entire worker population, Mallino evokes what has been labelled the “30% rule”. If the incidence of a particular disease in an exposed population of workers is 30% higher than in a comparable non-exposed population, that disease would be deemed to be work-related. To be eligible for workers’ compensation, a worker with that disease would simply have to prove that he or she was a member of an exposed group and that his or her level of exposure was sufficient to have been a factor in causing the disease (Mallino 1989).

We should note that this notion of probability has found its way into some legislation, such as, for example, Swiss legislation, which identifies two categories of disease. The second allows for recognizing cases that are not on the lists of occupational diseases or of chemical or physical agents recognized as noxious at the workplace. In the CNA’s actual practice, admissibility on the individual level also rests on the notion of probability, particularly for traumas to the musculoskeletal system.

Promoting rehabilitation and return to work—proposals by therapists

A major approach to minimizing the human and economic costs of workers’ compensation injuries and diseases involves promoting rehabilitation and early return to work. This is particularly applicable in cases of back injuries and other musculoskeletal disorders, which place a very heavy burden on WCS budgets in the United States and the countries of Northern Europe (Mikaelsson and Lister 1991; Aronoff et al. 1987).

According to Walsh and Dumitru (1988), the workers who have the most trouble returning to work after a lost-time illness are those with the best insurance. This fact should lead to a reform in the relations between the different actors. “Although progress in treatment is being made, modification of our present scheme of benefit disbursement seems necessary to optimize recovery after injury. Systems that reduce adversarial interactions between claimant, employer and insurer should be investigated.”

Aronoff et al. (1987) after evoking the costs of back pain in the United States, boosts methods of re-education that should permit insured persons to return to their jobs and to avoid falling into the trap of “chronic disability”.

“Impairment is a medical term, referring to reduction of body or organ function. Disability, a legal determination, refers to a task-specific limitation of performance. The chronic disability syndrome refers to a state in which individuals who are capable of working choose to remain disabled. The disability is often the result of a minor injury but actually represents an inability to cope with other life problems. The features of the syndrome are: out of work at least six months; disability claim and claim for financial compensation; subjective complaints disproportionate to objective findings; lack of motivation to recover and negative attitude toward return to work” (Aronoff et al. 1987).

Von Allmen and Ramaciotti (1993) analysed the process leading to chronic LBP among affected workers in different jobs. The complexity of the problem is even more manifest during a recession, when assignment changes and the possibility of returning to a less strenuous workplace are being more and more restricted.

The chronic disability syndrome is often associated with chronic pain. According to 1983 data from the United States, it is estimated that 75 to 80 million Americans suffer from chronic pain, generating annual costs between $65 and $60 billion. As many as 31 million of these individuals have lower back pain—almost two-thirds of whom report limitation of social and work functions. With chronic pain, the pain no longer serves an adaptive purpose but often becomes the disease itself (Aronoff et al. 1987).

Not all individuals with chronic pain are disabled, and many can be restored to productivity by referral to a chronic pain centre where the approach to such patients is multidisciplinary and features attention to the psychosocial aspects of the case. Success in such treatment is related to level of education, age (the older workers naturally having more trouble than younger ones in overcoming their mechanical problem) and duration of absence from the job prior to the referral (Aronoff et al. 1987).

Workers most likely to forego workers’ compensation benefits and return to work include those who have benefited from early intervention and referral for rehabilitation services as promptly as possible; those who effectively master the pain and are successful with stress reduction strategies; those with a positive work history; and those whose work offers a sense of purpose and job satisfaction. (Aronoff et al. 1987).

In some WCSs, benefits are cut off abruptly and the case closed as soon as a disabled worker returns to work. Then, if his or her disability recurs or new problems arise, the worker must face bureaucratic procedures and a more or less long wait for resumption of benefit payments. This is often a formidable obstacle to persuading workers that they are well enough to try returning to work. To overcome this, some WCSs allow a trial period when benefits are continued for a time during which the worker attempts to return to his or her old job or see if retraining has made him or her capable of performing a new job. Under these circumstances, the worker loses nothing if the trial turns out to be unsuccessful.

Ergonomic approaches: From the perspective of risk prevention

French-speaking ergonomists (members of SELF: an international society of French-speaking ergonomists) have shown the complex web of relations that link the job and accidents. Faverge (1977), based on studies conducted in coal mines by his collaborators, created a system of analysing accidents that today is applied in practice by the INRS in France.

It is not necessary for the effects on health to be serious and lead to grave injuries for the method to be useful. This is how very complicated links have been made between work with VDUs and visual fatigue (Rey, Meyer and Bousquet 1991).

In establishing these connections, the ergonomist has in his or her possession a precious tool for proposing preventive actions at different levels of the workflow.

Ergonomic analysis of the job has become a common technique that today goes beyond SELF, and the authors who are cited below include Americans and Canadians, as well as Europeans.

Ergonomic analysis of the job is original in that it cannot forego the worker’s participation. This is because, in addition to the knowledge that the worker has of the level of constraint that his or her job imposes, his or her perception of risk, as we explained above, depends on many factors that are foreign to the technical analysis of the situation conducted by the engineers and safety specialists.

In performing work tasks, the worker does not always follow exactly the advice of the safety specialist but relies also on his or her attitudes toward the job and perceptions of risks. As noted by Walters and Haines (1988):

Workers’ perceptions of hazards are formed and expressed in ways different from the dominant medical-technical paradigm in occupational health and safety. The main sources of information about chemicals, for example, are not supervisors, health representatives, or training courses, but their own experience, the observations of co-workers, or just their feelings. Workers employ a different complex of experience-based knowledge than is embodied in technical expertise.

In Quebec, Mergler (cited by Walters and Haines) has suggested (1987), that workers’ experience should be more fully recognised, since it does represent expressions of impairment. Having conducted numerous field studies, Mergler also knows that the workers’ testimony is difficult to obtain if they fear that by explaining their working conditions, they might lose their jobs.

With Durrafourg and Pélegrin (1993), we take even more distance from the cause-effect schemas of the insurers and safety officials. In order for prevention to be effective, according to these writers, the workers’ health and the work situation must be considered as a global system.

Although the major risks may have a preponderant cause (e.g., the level of noise to be heard or the presence of a noxious chemical substance for a poisoning), this is not the case for the majority of problems affecting working conditions, hygiene and safety. According to Durrafourg and Pélegrin, the risk in this case “is made up of the intersection of work demands, the condition of the workers, and the constraints of the situation on the job”.

If, for example, older workers have fewer accidents than workers with less seniority, this is because they have “acquired a knowledge of carefulness and of effective guidelines for avoiding danger”.

Ergonomic analysis should allow for identifying “the factors upon which it is possible to act to give a value to the knowledge of carefulness of men at work and to give them all the means they need to direct their health and safety”.

In brief, according to the ergonomists and labour doctors with modern training, risk is not expressed solely by a knowledge of the physical, chemical and bacteriological milieu, but also by a knowledge of the social milieu and the characteristics of workplace populations. A deeper study of the job, in the ergonomic sense of the word, should necessarily be conducted for every registered case. This effort at analysis is only very partially made by the existing authorities (workplace inspections, company health and safety services, medical services), but moving in this direction is necessary for effective prevention.

Equalization of social protection

Faced with rising costs due only in part to the costs of workers’ compensation and preventive programmes, employers are moving jobs from industrialized countries to less developed areas where wages and benefits are generally lower and health and safety regulations and administration are less burdensome. Faced with the need to install often costly preventive measures, some employers are simply closing down their enterprises and moving them to areas with lower wage costs. With this increase in unemployment, workers may have no jobs to return to when they are rehabilitated and, therefore, elect to continue to collect disability benefits for as long as possible (Euzéby 1993).

To meet the competition from low-wage areas, employers are reducing their workforce and demanding greater productivity from the workers they retain. With a simultaneous tendency to overlook or defer considerations of workplace safety, there may be more accidents and injuries putting additional pressure on the WCSs.

At the same time as workers’ compensation payments/premiums by employers—which are usually based on numbers of employees and a percentage of payroll—decline with workforce reductions, the resources of the WCSs may also be reduced. This has occurred in Switzerland, for example, where the CNA has had to reduce its own staff.

In the United States, a congressional movement to reduce the federal role in regulating and enforcing occupational and environmental health and safety laws and shifting it to the states and localities has not been accompanied by budgetary allocations and grants large enough to do this job properly.

Tchopp (1995) has called for an international equalization of social protection that will maintain the WCSs along with preventive programmes in developed countries and improve the working conditions and well-being in developing countries. The aim in these countries, he emphasizes, should be to improve the lives of their workers.


Although improvements are still possible, WCSs in general are doing a fair job of providing health care and rehabilitation services and disability benefits to workers with job-related injuries, but there are significant deficiencies in their handling of occupational diseases. The latter would be improved considerably by broadening the relevant legislation to include more bona fide occupational illnesses, improvements in the statistical systems and epidemiological studies that track their impact on the workforce, and appropriate recognition of medical and scientific developments demonstrating the multicausality of many of these diseases.

The role of WCSs in preventing occupational injuries and diseases, beyond providing data about their epidemiology, is problematic. The theory that effective approaches to prevention will lower employers’ costs for mandatory workers’ compensation taxes or insurance premiums does not always prove to be true in practice. In fact, some have argued for the separation of the prevention imperative from workers’ compensation administration and assigning it elsewhere, where occupational health and safety specialists may play a greater role. At the least, it requires appropriate governmental regulation and stronger enforcement, ideally internationalized to equalize conditions in developing countries with those in industrialized areas.

The ILO should encourage member countries to develop solid policies in the area of accident prevention and occupational diseases in the broadest sense.



In 1919, the year of its creation, the International Labour Organization (ILO) declared that anthrax was an occupational disease. In 1925, the first ILO List of Occupational Diseases was established by the Workmen’s Compensation (Occupational Diseases) Convention (No. 18). There were three occupational diseases listed. Convention No. 42 (1934) revised Convention No. 18 with a list of ten occupational diseases. In 1964, the International Labour Conference adopted the Employment Injury Benefits Convention (No. 121), this time with a separate schedule (List of Occupational Diseases) appended to the Convention, which allows for amending the schedule without having to adopt a new Convention (ILO 1964).

Definition of Work-Related Diseases and Occupational Diseases

In the third edition of the ILO’s Encyclopaedia of Occupational Health and Safety, a distinction was made among the pathological conditions that could affect workers in which diseases due to occupation (occupational diseases) and diseases aggravated by work or having a higher incidence owing to conditions of work (work-related diseases) were separated from conditions having no connection with work. However, in some countries work-related diseases are treated the same as work-caused diseases, which are in fact occupational diseases. The concepts of work-related diseases and occupational diseases have always been a matter of discussion.

In 1987, a joint ILO/WHO expert committee on occupational health offered the suggestion that the term work-related diseases may be appropriate to describe not only recognized occupational diseases, but other disorders to which the work environment and performance of work contribute significantly as one of the several causative factors (Joint ILO/WHO Committee on Occupational Health 1989). When it is clear that a causal relationship exists between an occupational exposure and a specific disease, that disease is usually considered both medically and legally as occupational and may be defined as such. However, not all work-related diseases can be defined so specifically. The ILO Employment Injury Benefits Recommendation, 1964 (No. 121), paragraph 6(1), defines occupational disease as follows: “Each Member should, under prescribed conditions, regard diseases known to arise out of the exposure to substances and dangerous conditions in processes, trades or occupations as occupational diseases.”

Nevertheless, it is not always that easy to designate a disease as being work-related. In fact, there is a wide range of diseases that could be related in one way or another to occupation or working conditions. On the one hand, there are the classical diseases that are occupational in nature, generally related to one causal agent and relatively easy to identify. On the other hand, there are all sorts of disorders without strong or specific connections to occupation and with numerous possible causal agents.

Many of these diseases with a multifactorial aetiology may be work-related only under certain conditions. The subject was discussed at an international symposium on work-related diseases organized by the ILO in Linz, Austria, in October 1992 (ILO 1993). The relationship between work and disease could be identified in the following categories:

  • occupational diseases, having a specific or a strong relation to occupation, generally with only one causal agent, and recognized as such
  • work-related diseases, with multiple causal agents, where factors in the work environment may play a role, together with other risk factors, in the development of such diseases, which have a complex aetiology
  • diseases affecting working populations, without causal relationship with work but which may be aggravated by occupational hazards to health.


Criteria for Identification of Occupational Diseases in General

Two main elements are present in the definition of occupational diseases:

  • the exposure-effect relationship between a specific working environment and/or activity and a specific disease effect
  • the fact that these diseases occur among the group of persons concerned with a frequency above the average morbidity of the rest of the population.


It is apparent that the exposure-effect relationship must be clearly established: (a) clinical and pathological data and (b) occupational background and job analysis are indispensable, while (c) epidemiological data are useful, for determining the exposure-effect relationship of a specific occupational disease and its corresponding activity in specific occupations.

As a general rule, the symptoms of such disorders are not sufficiently characteristic to enable occupational diseases to be diagnosed other than on the basis of the knowledge of the pathological changes engendered by the physical, chemical, biological or other factors encountered in the exercise of an occupation. It is therefore normal that, as a result of the improvement of knowledge regarding the action processes of the factors in question, the steady increase in the number of substances employed, and the quality used or the variety of agents suspected, it should be more and more possible to make an accurate diagnosis while at the same time broadening the range of these diseases. Parallel with the boom in the research in this field, the development and refinement of epidemiological surveys have made a substantial contribution towards furthering the knowledge of exposure/effect relationships, making it easier, inter alia, to define and identify the various occupational diseases. The identification of a disease as being of occupational origin is, in reality, a specific example of clinical decision-making or applied clinical epidemiology. Deciding on the cause of a disease is not an exact science but rather a question of judgement based on a critical review of all the available evidence, which should include a consideration of:

  • Strength of association. An occupational disease is one where there is an obvious and real increase in disease in association with exposure to the risk.
  • Consistency. The various research reports have generally similar results and conclusions.
  • Specificity. The risk exposure results in a clearly defined pattern of disease or of diseases and not simply in an increasing number of causes of morbidity or mortality.
  • Appropriate time relationship. The disease follows after the exposure and with an appropriate time interval.
  • Biological gradient. The greater the level of exposure, the greater the prevalence of severity of diseases.
  • Biological plausibility. From what is known of toxicology, chemistry, physical properties or other attributes of the studied risk, it does really make biological sense to suggest that the exposure leads to a certain disorder.
  • Coherence. A general synthesis of all the evidence (human epidemiology, animal studies and so on) leads to the conclusion that there is a causative effect in its broad sense and in terms of general common sense.


The magnitude of the risk is another basic element generally used for determining whether a disease is to be considered occupational in origin. Quantitative and qualitative criteria play an important role in evaluating the risk of contracting an occupational disease. Such a risk may be expressed either in terms of its magnitude—for instance, the quantities in which the substance is employed, the number of workers exposed, the prevalence rates for the disease in different countries—or in terms of the seriousness of the risk, which may be assessed on the basis of its effects upon workers’ health (e.g., the likelihood of its causing cancer or mutations or having highly toxic effects or leading in due course to disablement). It should be noted that the figures available as to prevalence rates and the degree of seriousness of occupational diseases should be viewed with some circumspection due to the differences in procedures for reporting cases and compiling and evaluating data. The same is true for the number of workers exposed, as figures can only be approximate.

Finally, at the international level, another very important factor must be taken into account: the fact that the disease is recognized as being occupational by the law of a certain number of countries constitutes an important criterion on which to base a decision to include it in the international list. It may indeed be considered that its incorporation in the list of diseases carrying entitlement to benefit in a large number of countries shows that it is of considerable social and economic importance and that the risk factors involved are recognized and widely encountered.

To summarize, criteria for determining a new occupational disease to be added on an international list are: the strength of the exposure-effect relationship, the occurrence of the disease with specific activity or specific work environment (which includes the occurrence of the event and a specific nature of this relationship), the magnitude of the risk on the basis of the number of workers exposed or the seriousness of the risk, and the fact that a disease is recognized on many national lists.

Criteria for Identification of an Individual Disease

The exposure-effect relationship (relation between exposure and the severity of the impairment in the subject) and the exposure-response relationship (connection between exposure and the relative number of subjects affected) are important elements for the determination of occupational diseases, which research and epidemiological studies have greatly contributed to developing in the last decade. This information pertaining to the causal relationship between diseases and exposure in the workplace has allowed us to achieve a better medical definition of occupational diseases. Therefore it follows that the legal definition of occupational diseases, which was a rather complex problem before, is becoming more and more linked to the medical definitions. The legal system entitling the victim to compensation varies from country to country. Article 8 of the Employment Injury Benefits Convention (No. 121), which indicates the various possibilities regarding the form of the schedule of occupational diseases entitling workers to a compensation benefit, states:

Each Member shall:

  1. prescribe a list of diseases, comprising at least the diseases enumerated in Schedule I to this Convention, which shall be regarded as occupational diseases under prescribed conditions; or
  2. include in its legislation a general definition of occupational diseases broad enough to cover at least the diseases enumerated in Schedule I to this Convention; or
  3. prescribe a list of diseases in conformity with clause (a), complemented by a general definition of occupational diseases or by other provisions for establishing the occupational origin of diseases not so listed or manifesting themselves under conditions different from those prescribed.

Point (a) is called the list system, point (b) is the general definition system or overall coverage system while point (c) is generally referred to as the mixed system.

While the list system has the disadvantage of covering only a certain number of occupational diseases, it has the advantage of listing diseases for which there is a presumption that they are of occupational origin. Frequently it is very difficult if not impossible to prove that a disease is directly attributable to the victim’s occupation. Paragraph 6(2) of Recommendation No. 121 indicates that “Unless proof to the contrary is brought, there should be a presumption of the occupational origin of such diseases” (under prescribed conditions). It also has the important advantage of indicating clearly where prevention should take place.

The general definition system covers theoretically all occupational diseases; it affords the widest and most flexible protection, but leaves it to the victim to prove the occupational origin of the disease, and no emphasis is placed on specific prevention.

Because of this marked difference between a general definition and a list of specific diseases, the mixed system has been favoured by many ILO Member States because it combines the advantages of the two others without their disadvantages.

List of Occupational Diseases

Convention No. 121 and Recommendation No. 121

The ILO list plays a key role in harmonizing the development of policy on occupational diseases and in promoting their prevention. It has in fact achieved considerable status in the field of occupational health and safety. It presents a clear statement of diseases or disorders that can and should be prevented. As it is, it does not include all occupational diseases. It should represent those that are most common in the industries of many countries and where prevention can have the greatest impact on the health of workers.

Because the patterns of employment and risks are changing greatly and continuously in many countries, and because of the evolution of knowledge on occupational diseases through epidemiological studies and research, the list must be modified and added to, reflecting an updated state of knowledge, to be fair to the victims of these diseases.

In developed countries, heavy industries such as steel fabrication and underground mining have greatly diminished, and environmental conditions have improved. Service industries and automated offices have risen in relative importance. A far greater proportion of the workforce is made up of women who still, for the most part, manage the home and care for children in addition to working on the outside. The need for day care for children is increasing while these developments place added stress on women. Night work and rotating shift work have become a normal pattern. Stress, in all aspects, is now an important problem.

In developing countries, heavy industries are rising rapidly to supply local and export needs, and providing employment to these burgeoning populations. Rural populations are moving to cities in search of employment and to escape poverty.

The human health risks of some new chemicals are known, and special emphasis is given to short-term biological tests or to long-term animal exposures for the purpose of toxicological and carcinogenic incidence. Exposures of working populations in most developed countries are probably controlled at low levels, but no such assurance can be assumed for the use of chemicals in many other nations. A particularly important example is provided by the use of pesticides and herbicides in agriculture. Although there can be no serious doubt that they increase crop yields in the short term as well as increasing the control of vector-borne diseases such as malaria, we do not know clearly in which controlled conditions they can be used without major impact on the health of agricultural workers or those who eat the foods so produced. It seems that in certain countries, very large numbers of agricultural workers have been poisoned by their use. Even in well industrialized countries the health of farm workers is a serious problem. The isolation and lack of supervision place them at real risk. A prominent issue is provided by the continued manufacture of some chemicals in countries where their use is banned, in order to export these chemicals to countries where no such ban exists.

The design and function of enclosed modern buildings in industrialized countries and of the electronic office equipment within them have received close attention. Continuous repetitive movements are widely considered to be the cause of debilitating symptoms.

Tobacco smoke in the workplace, although not seen as a cause of occupational disease by itself, seems likely to be an issue in the future. Non-smokers are increasingly intolerant of the perceived health hazard from the smoke emitted by smokers in the vicinity. The pressure to sell tobacco products in developing countries is likely to produce an unprecedented epidemic of diseases in the near future. Exposure of non-smokers to tobacco smoke pollution will have to be taken as a matter of increasing consideration. Relevant legislation is already in place in some countries. A most important hazard is associated with health care workers who are exposed to a wide variety of chemicals, sensitizers and infections. Hepatitis and AIDS provide special examples.

The entry of women into the workforce in all countries underlies the problem of reproductive disorders associated with workplace factors. These include infertility, sexual dysfunction and effects on foetus and pregnancy when the women are exposed to chemical agents and workplace factors, including ergonomic strain. There is increasing evidence that the same problems may affect male workers.

Within this framework of changing populations and changing patterns of risk, it is necessary to review the list and add those diseases identified as being occupational. The list appended to Convention No. 121 should accordingly be brought up to date so as to include the disorders most widely recognized as being of occupational origin and those involved in most dangers to health. In this regard, an informal consultation on the revision of the list of occupational diseases appended to Convention No. 121 was held by the ILO in Geneva in December 1991. In their report, the experts proposed a new list, which is shown in table 1.

Table 1. Proposed ILO list of occupational diseases


Diseases caused by agents



Diseases caused by chemical agents




Diseases caused by beryllium or its toxic compounds




Diseases caused by cadmium or its toxic compounds




Diseases caused by phosphorus or its toxic compounds




Diseases caused by chromium or its toxic compounds




Diseases caused by manganese or its toxic compounds




Diseases caused by arsenic or its toxic compounds




Diseases caused by mercury or its toxic compounds




Diseases caused by lead or its toxic compounds




Diseases caused by fluorine or its toxic compounds




Diseases caused by carbon disulphide




Diseases caused by the toxic halogen derivatives of aliphatic or aromatic hydrocarbons




Diseases caused by benzene or its toxic homologues




Diseases caused by toxic nitro- and amino-derivatives of benzene or its homologues




Diseases caused by nitroglycerin or other nitric acid esters




Diseases caused by alcohols glycols or ketones




Diseases caused by asphyxiants: carbon monoxide hydrogen cyanide or its toxic derivatives hydrogen sulphide




Diseases caused by acrylonitrite




Diseases caused by oxides of nitrogen




Diseases caused by vanadium or its toxic compounds




Diseases caused by antimony or its toxic compounds




Diseases caused by hexane




Diseases of teeth due to mineral acids




Diseases due to pharmaceutical agents




Diseases due to thallium or its compounds




Diseases due to osmium or its compounds




Diseases due to selenium or its toxic compounds




Diseases due to copper or its compounds




Diseases due to tin or its compounds




Diseases due to zinc or its toxic compounds




Diseases due to ozone, phosgene




Diseases due to irritants: benzoquinone and other corneal irritants




Diseases caused by any other chemical agents not mentioned in the preceding items 1.1.1 to 1.1.31 where a link between the exposure of a worker to this chemical agent and the disease suffered is established.



Diseases caused by physical agents




Hearing impairment caused by noise




Diseases caused by vibration (disorders of muscles, tendons, bones, joints, peripheral blood vessels or peripheral nerves)




Diseases caused by work in compressed air




Diseases caused by ionizing radiation




Diseases caused by heat radiation




Diseases caused by ultra violet radiation




Diseases due to extreme temperature (e.g., sunstroke, frostbite)




Diseases caused by any other physical agents not mentioned in the preceding items 1.2.1 to 1.2.7 where a direct link between the exposure of a worker to this physical agent and the disease suffered is established.



Biological agents




Infections or parasitic diseases contracted in an occupation where there is a particular risk of contamination


Diseases by target organ systems



Occupational respiratory diseases




Pneumoconioses caused by sclerogenic mineral dust (silicosis, anthraco-silicosis, asbestosis) and silicotubercolosis, provided that silicosis is an essential factor in causing the resultant incapacity or death




Bronchopulmonary diseases caused by hard-metal dust




Bronchopulmonary diseases caused by cotton, flax, hemp or sisal dust (byssinosis)




Occupational asthma caused by recognized sensitizing agents or irritants inherent to the work process




Extrinsic allergic alveolitis caused by the inhalation of organic dusts as prescribed by national legislation








Chronic obstructive pulmonary diseases




Diseases of lung due to aluminium




Upper airways disorders caused by recognized sensitizing agents or irritants inherent to the work process




Any other respiratory disease not mentioned in the preceding items 2.1.1 to 2.1.9 caused by an agent where a direct link between the exposure of a worker to this agent and the disease suffered is established



Occupational skin diseases




Skin diseases caused by physical, chemical, or biological agents not included under other items




Occupational vitiligo



Occupational musculo-skeletal disorders




Musculo-skeletal diseases caused by specific work activities or work environment where particular risk factors are present.

Examples of such activities or environment include:

(a) Rapid or repetitive motion

(b) Forceful exertions

(c) Excessive mechanical force concentrations

(d) Awkward or non-neutral postures

(e) Vibration

Local or environmental cold may potentiate risk.




Miner’s nystagmus


Occupational cancer



Cancer caused by the following agents:








Benzidine and salts




Bichloromethyl ether (BCME)




Chromium and chromium compounds




Coal tars and coal tar pitches; soot








Vinyl chloride




Benzene or its toxic homologues




Toxic nitro- and amino-derivatives of benzene or its homologues




Ionizing radiation




Tar, pitch, bitumen, mineral oil, anthracene, or the compounds, products or residues of these substances




Coke oven emissions




Compounds of nickel




Dust from wood




Cancer caused by any other agents not men- tioned in the preceding items 3.1.1 to 3.1.14 where a direct link between the exposure of a worker to this agent and the cancer suffered is established.

In their report, the experts indicated that the list should be brought up to date regularly to contribute to harmonizing social security benefits at the international level. It was clearly indicated that there is no moral or ethical reason to recommend standards in one country that are lower than those in another. Additional reasons to revise this list frequently include (1) stimulating the prevention of occupational diseases by facilitating a greater awareness of the risks involved in work, (2) encouraging combating the use of harmful substances, and (3) keeping workers under medical surveillance. The prevention of occupational diseases remains an essential objective of any system of social security concerned with the protection of workers’ health.

A new format has been proposed, breaking down the list into the three following categories:

  1. diseases caused by agents (chemical, physical, biological)
  2. diseases of target organ systems (respiratory, skin, musculoskeletal)
  3. occupational cancer.




Part I. The Body
Part II. Health Care
Part III. Management & Policy
Part IV. Tools and Approaches
Part V. Psychosocial and Organizational Factors
Part VI. General Hazards
Part VII. The Environment
Part VIII. Accidents and Safety Management
Part IX. Chemicals
Part X. Industries Based on Biological Resources
Part XI. Industries Based on Natural Resources
Part XII. Chemical Industries
Part XIII. Manufacturing Industries
Part XIV. Textile and Apparel Industries
Part XV. Transport Industries
Part XVI. Construction
Part XVII. Services and Trade
Part XVIII. Guides