Examination of insured events in connection with an occupational disease. Occupational Safety and Health

OCCUPATIONAL SAFETY AND HEALTH
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Examination of insured events in connection with an occupational disease. Occupational Safety and Health

Occupational Safety and Health

Occupational Safety and Health / Legislative basis for labor protection

After the fact occupational disease established, the insurer must carry out an examination of the insured event and assign insurance coverage to the injured insured employee. Since the examination of insurance cases in connection with an occupational disease is quite a complex matter, especially in the constantly transforming legislation, the Social Insurance Fund of the Russian Federation specifically for information and use in its work concretized and systematically outlined certain legal, procedural and methodological aspects of such an examination of insurance cases.

1. Concepts and signs of an insured event in connection with an occupational disease

Federal Law No. 24-FZ of July 1998, 125 and Decree of the Government of the Russian Federation No. 15 of December 2000, 967 connect the insured person’s occupational disease with an insured event, which entails the insurer’s obligations to provide insurance, with two forms of the disease: arising suddenly and occurring acutely; manifesting periodically after a certain period of work activity in the form of a chronic pathology that develops slowly depending on the duration and extent of exposure of the body to a harmful pathogenic factor.

The occurrence of both acute and chronic occupational diseases in an employee (insured) is possible only under working conditions that are characterized by the presence of harmful production factors in the workplace that exceed hygienic standards and can have an adverse effect on the health of the employee (insured). No other rules and conditions for recognizing a disease by professional law have been established.

Only an employee (individual) whose occupational disease was diagnosed during his employment relationship with the employer (insured) under an employment or fixed-term employment agreement (contract) can be insured. In this case, information about the obligations of the employee and employer, the work performed and length of service is documented in the employment contract, as well as in the work book in accordance with the Labor Code of the Russian Federation. This information must be confirmed during an insurance examination.

Failure to confirm during the examination the essential features of an insured event (harmful production conditions, labor relations) defined by the legislation on compulsory social insurance against industrial accidents and occupational diseases entails non-recognition of this event as insured.

2. Main stages of examination of an insured event

The legal fact of recognizing an occupational disease as an insured event, which entails the insurer’s obligation to provide insurance coverage, is established through a consistent examination of the circumstances, conditions and reasons that caused this acute or chronic occupational disease, consisting of the following:

1) the occurrence of an acute or diagnosis of a chronic disease (pathology) with temporary loss of professional ability by an employee (insured) necessitates the need for the doctor of a medical institution to enter information about this disease, its manifestations, possible cause, and preliminary main diagnosis of the disease into the medical record of an outpatient or inpatient patient with the registration of a certificate of incapacity for work, the justification and reason for its issuance;

2) establishment of a preliminary main diagnosis of the disease, acute or chronic, its differential diagnosis, timing and scope of its implementation, taking into account the results of specific instrumental and laboratory research methods, anamnestic data on the presence of occupational hazards, damage to organs and systems characteristic of these hazards, conclusions of specialized specialists, making the necessary changes and additions to the medical documentation, substantiating the preliminary main diagnosis of an occupational disease, drawing up and sending a notice of establishing a preliminary diagnosis of an acute or chronic occupational disease of an employee (insured), drawing up a “sanitary and hygienic characteristics of the working conditions of an employee if he is suspected of having an occupational disease” illness (poisoning) is carried out by a medical institution at the place of residence or work of the insured;

3) assessment of sanitary and hygienic working conditions at the workplace of a sick employee (insured), the presence, duration and intensity of exposure to specific occupational hazards (harmful production factors) as possible causes of the occurrence, development and course of an occupational disease with temporary loss of ability to work, drawing up a sanitary and hygienic report characteristics of the employee’s working conditions are produced by the territorial center of Rospotrebnadzor at the location of the employer (insured);

4) establishing the final main diagnosis of an acute occupational disease, taking into account the sanitary and hygienic characteristics of the employee’s working conditions, drawing up a medical report is carried out by the medical institution by entering the relevant information into the medical documentation and certificate of incapacity for work (approved by order of the Ministry of Health and Social Development of Russia dated March 18, 2007 No. 172 ) with its closure and recommendations regarding work ability. Acute occupational diseases in an employee (insured), as a rule, result in recovery and return to work. If a medical and preventive institution identifies signs of permanent disability due to an acute occupational disease, the employee (insured) with an open certificate of incapacity for work is sent to a medical and social examination institution based on the decision of the clinical expert commission (CEC) for the examination of temporary disability with the entry of data on the sick person into journal of KEK decisions, as well as sending to the insured and to the territorial center of Rospotrebnadzor “Notices on the establishment of the final diagnosis of an acute occupational disease (poisoning), its clarification or cancellation”;

5) establishment of the final main diagnosis of a chronic occupational disease with the entry of relevant data into the medical documentation and certificate of incapacity for work on the basis of a medical report is carried out by the Center for Occupational Pathology, which established this final diagnosis. The closure of the certificate of incapacity for work or the registration in the prescribed manner (based on the decision of the EEC) of a referral to a medical and social examination institution in order to establish a permanent loss of professional ability to work is carried out by a medical institution that has established a preliminary diagnosis of a chronic disease. Entering information about the sick person into the register of occupational diseases at the occupational pathology center. Sending by this occupational pathology center to the insured, the insurer, the territorial center of Rospotrebnadzor and the treatment and preventive institution that referred the patient, notices of the final diagnosis of a chronic occupational disease (poisoning), its clarification or cancellation;

6) assessment by the territorial center of Rospotrebnadzor of the circumstances and causes of acute or chronic occupational disease of an employee (insured) on the basis of sanitary and hygienic characteristics of working conditions, expert opinions, results of research and experiments, accidents and violations of the operation of technological equipment, instruments and apparatus, duration and intensity exposure to specific occupational hazards (harmful production factors) with drawing up a report on the case of occupational disease.

Examination of harmful production factors

In accordance with the legislation in the Russian Federation, maximum permissible concentrations (MPC) of toxic substances and maximum permissible levels (MPL) of exposure to occupational hazards have been established, which exclude the possibility of developing both acute and chronic occupational diseases.

Therefore, the statement of information about harmful production factors and conclusions regarding their ability, with a single or long-term exposure, to cause an occupational disease must be consistent when drawing up sanitary and hygienic working conditions and/or a report on a case of occupational disease with the provisions of Guideline R 2.2.2006-05.

According to this guide, not all harmful production factors can cause an occupational disease, temporary or permanent disability, but only those that are characterized by a certain level of harmful substance content in the workplace, the intensity and duration of its impact on the worker (insured) in production conditions.

Causal relationship of an occupational disease with production

When examining sanitary and hygienic working conditions and drawing up a report on a case of occupational disease in order to recognize the connection between a harmful production factor characterizing the working conditions at the workplace of an employee (insured) with his disease, which is subsequently recognized as occupational, it is necessary to compare them depending on the class and degree of harm working conditions, from the possibility of causing temporary or permanent loss of professional ability to work.

The illegality of establishing a connection between the illness of an employee (insured) and optimal, acceptable and harmful working conditions that do not lead to an occupational disease follows from the conditions of Guideline R 2.2.2006-05, however, the identified circumstances do not allow one to cancel the diagnosis of an occupational disease due to incorrect conclusions made when drawing up sanitary and hygienic characteristics of working conditions or a report on a case of occupational disease. At the same time, the statement that this occupational disease cannot be associated with working conditions at the insured’s place of work obliges to establish this place of work and draw up a report on the case of an occupational disease in connection with the production where the insured worked and these harmful working conditions could have occurred.

This confirms that a report on a case of occupational disease is drawn up when the diagnosis of an occupational acute or chronic disease has already been previously established by a medical institution, taking into account the conditions and factors of production, information about which is reflected in the sanitary and hygienic characteristics of the workplace, and is confirmed by the final diagnosis of the center occupational pathology in the case of a chronic occupational nature of the disease.

A report on a case of occupational disease is drawn up and approved by specialists of the state sanitary and epidemiological service. By its legal force and purpose, this act does not establish or cancel the diagnosis of an occupational disease, but only establishes and confirms the cause-and-effect relationship of this disease with harmful working conditions, the duration and intensity of their impact at the place of work of the sick employee (insured).

An established diagnosis of an acute or chronic occupational disease can be changed or canceled by the center of occupational pathology based on the results of additional research and examination (clause 14 of the Decree of the Government of the Russian Federation of December 15, 2000 No. 967).

Such results of additional research and examination may be data from an investigation of an occupational disease, information set out in the sanitary and hygienic characteristics of working conditions or a report on a case of occupational disease.

Materials of the sanitary and hygienic characteristics of working conditions and the act, which do not confirm the cause-and-effect relationship of an acute or chronic occupational disease of an employee (insured) with the conditions of his production activities at his main or other place of work, are the basis for initiating a procedure for canceling the diagnosis of an occupational disease by the center of occupational pathology.

At the same time, according to the Instructions on the procedure for applying the Regulations on the investigation and recording of occupational diseases (approved by order of the Ministry of Health of Russia dated May 28, 2001 No. 176) for each case of acute or chronic occupational disease (poisoning), not accompanied by temporary loss of ability to work by the employee (insured ), the health care institution also draws up a notice, conducts an investigation, draws up a sanitary and hygienic description of working conditions, and also draws up a report on the case of an occupational disease.

All this leads to the fact that persons who have not lost temporary professional ability to work, having in their hands a report on a case of occupational disease, apply to any medical and social examination institution, which, without any other medical reports and documents, establishes the fact of permanent loss of professional ability to work in connection with an insured event (occupational disease), which is not actually qualified and not confirmed by medical documents in the prescribed manner, first of all, a certificate of incapacity for work and payment of insurance benefits in connection with the insured event.

There are cases when occupational pathology centers, for the first time establishing the chronic occupational nature of the disease in an employee (insured person), do not determine the possibility of loss of ability to work or note that in connection with the work performed by the employee (insured person), loss of ability to work did not occur. At the same time, in certificates and other arbitrary forms issued to employees (insured), they are recommended to contact a medical and social examination institution to establish a permanent loss of professional ability to work. These circumstances may also be grounds for not recognizing this occupational disease as an insured event.

Examination of documents confirming the insured event

The insurer should begin and carry out an examination of an insured event in connection with an occupational disease not with a report on an event of an occupational disease, but with the fact of damage to health, from the moment of the occurrence of an acute or diagnosed chronic illness of an employee (the insured), which arose as a result of exposure to harmful production factors and caused his temporary loss of professional ability to work. Confirmation of all this is a certificate of incapacity for work - the main document characterizing the legal fact of the occurrence of an insured event in this type of insurance, as well as officially approved forms of medical documents.

When an employee (insured) applies to a medical institution in connection with an acute or diagnosed chronic disease that has arisen for the first time, as well as suspicions about its professional nature, one should proceed from the norms and provisions of the legislation on health protection, according to which those who apply to a medical institution the insured must have manifestations and signs of a disease that has created significant difficulties at work, leading to temporary disability with the issuance of a certificate of incapacity for work as the basis for assigning insurance coverage against industrial accidents and occupational diseases.

Initially, the healthcare institution is obliged to send a notice of the establishment of a preliminary diagnosis of an acute (within 3 hours) or diagnosis of a chronic (within XNUMX days) occupational disease of the employee (insured) to the territorial center of Rospotrebnadzor, inform the employer (insurer), who in turn is obliged notify the executive body of the Social Insurance Fund of the Russian Federation of a suspected insured event in connection with an occupational disease.

A notification (message) about the establishment of a preliminary diagnosis of an occupational disease is sent to the territorial center of Rospotrebnadzor and the employer (insurer) in the presence of medical documents and a certificate of incapacity issued in connection with the suspicion of this disease, taking into account and in the presence of which the rights and obligations of the policyholder, insurer and insured in compulsory social insurance against accidents at work and occupational diseases.

Actually, from this moment an examination of an insured event caused by an occupational disease should be carried out.

Upon suspicion of an insurable nature of the disease, the insurer evaluates the medical documentation (medical record of an outpatient or inpatient patient), the information it contains about the insured person’s diseases and their causes, the frequency of visits, clinical manifestations of diseases, anamnestic and other data that allows establishing a connection between the disease and occupational health. labor activity.

Materials characterizing the process of establishing the diagnosis of the disease and the causes that caused it, both in relation to acute and chronic occupational diseases, are subject to analysis.

The information necessary for the examination is clarified, confirmed and compared according to the accounting forms of medical documents, terms, criteria, connections, conclusions and results contained in them. The timing of sending a notice of a preliminary diagnosis of an acute or chronic occupational disease, the preliminary diagnosis of the disease indicated in it, the factors and causes that caused the occupational disease are compared with medical documentation data, a certificate of incapacity for work, and with the sanitary and hygienic characteristics of the working conditions of the employee (insured).

A health care institution, based on clinical data of the employee’s health status and the sanitary and hygienic characteristics of his working conditions, establishes a final diagnosis of an acute occupational disease, draws up a medical report, sends a notice of the final diagnosis of an acute occupational disease to the territorial center of Rospotrebnadzor, the employer (insurer), and the insurer, and also data on its clarification or cancellation, the names of harmful production factors and the reasons that caused the occupational disease. The law and regulations do not provide for instructions on sending an employee (insured) in connection with an acute occupational disease to an occupational pathology center.

An acute occupational disease that occurs suddenly during a working day or shift can only occur in the insured during the period of his working activity. The final diagnosis of an acute occupational disease does not require confirmation and is not the basis for contacting an occupational pathology center.

This statement should be fully attributed to infectious occupational pathology. Diagnosis of an infectious disease for the first time, as a rule, indicates the acute nature of the disease, the causes and conditions of the occurrence of which require a thorough sanitary and epidemiological examination, identification of sources, routes and factors of transmission of infection, as well as substantiation of the conclusions made by the results of laboratory and instrumental methods of examination and research of patients and the external environment surrounding the sick person.

An occupational disease as an insured event that caused temporary disability of an employee (insured) and the need to pay for insurance coverage in connection with temporary disability is assessed by the insurer in the manner and according to the rules adopted for the examination of temporary disability in medical institutions. At the same time, the possibilities of restoring working capacity are analyzed taking into account medical documents, which reflect the objective status and justify the rationale for closing or continuing the temporary disability certificate. A decision is made on the need for temporary transfer of able-bodied persons for health reasons to another job or their rational employment. Signs of chronic pathology and permanent disability are identified, and measures are taken to refer the employee (insured person) to the occupational pathology center to resolve the issue of further treatment (due to the occupational nature of the disease) or for examination at a medical and social examination institution.

The conclusion of the clinical expert commission is recorded in the medical history (outpatient card), the book of records of the commission's conclusions, and is documented in a decision protocol signed by the chairman and members of the commission.

When sending an employee (insured person) for a medical and social examination, the date of referral is indicated in the appropriate column, the certificate of incapacity for work is signed by the attending physician and members of the clinical expert commission.

If an employee (insured) is recognized as having permanently lost professional ability to work, the medical and preventive institution closes the certificate of incapacity for work with the date of registration of the referral in form 088/u-06, approved by order of the Ministry of Health and Social Development of Russia dated January 31, 2007 No. 77, by the medical and social examination institution.

At the same time, the establishment or non-recognition by a medical institution of a final diagnosis of an acute occupational disease with or without possible loss of ability to work does not entail the need for the employee (insured) to contact the center of occupational pathology.

The procedure for examining an insured event in connection with an occupational disease and temporary disability is implemented by analogy with the procedure adopted for establishing disability.

Depending on the duration of temporary disability by the insurer in accordance with the “Estimated periods of temporary disability for the most common diseases and injuries (in accordance with ICD-10)” (approved by the Ministry of Health of Russia dated August 21, 2000 No. 2510/9362-34; Social Insurance Fund Russian Federation dated August 21, 2000 No. 02-08/10-1977P) assess the severity of the disease, its possible outcome in the form of recovery and return of the insured to work or referral to an occupational pathology center or a medical and social examination institution.

It should be borne in mind that the “Regulations on the investigation and recording of occupational diseases” (clause 13) stipulate that a medical institution that has established a preliminary diagnosis of a chronic occupational disease (poisoning) is obliged to refer the sick employee (the insured person) within a month ) to the center of occupational pathology with an extract from the medical record of an outpatient and/or inpatient, information on the results and timing of preliminary and periodic medical examinations, sanitary and hygienic characteristics of working conditions, copies of the employment contract and work record book. If there is a suspicion of a connection between the disease and an occupational disease, an examination at the occupational pathology center must be carried out with an open certificate of incapacity for work and in the direction of a medical institution, issued in the prescribed manner.

A referral to an occupational pathology center is documented by a protocol of the decision of the clinical expert commission of a medical institution that has established a preliminary diagnosis of a chronic occupational disease that caused temporary disability, with a note on the certificate of incapacity for work.

Protocol The decision of the clinical expert commission (CEC) during the examination of temporary disability due to an occupational disease must contain the following information about the sick employee (insured), which is reflected in the direction:

1) last name, first name, patronymic;

2) date of birth;

3) gender;

4) address (place of residence);

5) place of work (name of the policyholder);

6) number and date of signing of the employment contract;

7) profession, work experience in this profession;

8) is or has been under treatment (name of the department and medical institution that established a preliminary diagnosis of a chronic occupational disease);

9) duration and terms of temporary disability, sick leave number;

10) clinical diagnosis (ICD-10):

a) underlying disease;

b) concomitant disease;

c) complications;

11) dynamics of the disease over the past month;

12) protocol-decision of the commission (KEC).

The Center for Occupational Pathology, based on clinical data on the course of the employee’s (insured’s) illness, and, if necessary, taking into account the results of his additional observation, examination and research in an outpatient or inpatient setting of the center, as well as taking into account the submitted documents, establishes a final diagnosis of a chronic occupational disease and 3 - a day period sends a corresponding notice to the territorial center of Rospotrebnadzor, the employer, the insurer and the health care institution that referred the patient.

A chronic occupational disease as an insured event is assessed in the manner established for insured events caused by an acute occupational disease with temporary disability, or recovery and return to work, or the establishment of permanent loss of professional ability.

The investigation of each case of acute or chronic occupational disease is carried out by the commission on the basis of an order issued by the employer from the moment of receipt of notification of the final diagnosis with the drawing up of a report on the case of occupational disease.

Recognition of an acute or chronic occupational disease as an insured event under compulsory social insurance against industrial accidents and occupational diseases is possible in the presence of all the necessary medical and other supporting documents characterizing the health damage of the employee (insured), an employment contract with the employer (insured) at the time of occurrence an insured event caused by the impact of harmful factors, the duration and intensity of their impact, resulting in temporary disability and the insurer’s obligations to provide security for this type of insurance.

In other words, it can be argued that an occupational disease is qualified and recognized as an insured event from the date of the onset of temporary disability and the issuance of a certificate of incapacity for work in connection with the insured event for the insured (an employee in an employment relationship with the employer), and permanent loss of professional ability, including on the basis of a report on a case of occupational disease, characterizes the labor prognosis and outcome of an occupational disease that has already been recognized or not recognized as an insured event.

Authors: Fainburg G.Z., Ovsyankin A.D., Potemkin V.I.

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