You have been the victim of an accident or injury caused by a third party ? You can report it to Health Insurance

Accidents et blessures causées par un tiers, déclarez-les à l’Assurance-maladie !

Any person who is the victim of an accident or injury caused by a third party – an individual, a company or a community – must report it to Health Insurance. Why ? What impact on health care reimbursements ? How to initiate this process called “recourse against third parties” ? Practical guide.

If an injury or accident is caused by a third party, the primary health insurance fund (CPAM) must be informed. This will allow it to take action against the person responsible (or their work accident, disability pension, but also medical, pharmaceutical or equipment costs.

Thanks to this approach of recourse against third parties, it is not the Health Insurance that suffers the financial consequences of the event, but the insurance company of the third party responsible, or failing that, the third party himself. In addition, this reporting can also allow you to obtain compensation and reimbursement of the costs remaining the victim's responsibility.

What accidents and injuries are we talking about ?

You are concerned if you – as an insured person affiliated to the general social security scheme or a relative (declaring on behalf of a victim) – have suffered injuries caused intentionally or by the fault, imprudence or negligence of an identified third party, originating from:

a traffic accident (by car, bicycle, on foot, scooter, wheelchair, etc.). 65% of third-party claims are traffic accidents; intentional assault and battery (with complaint filed and observation of injuries); an accident on public transport; a sports or leisure accident (match, outing or supervised activity, etc.); an animal bite or a fall caused by an animal; an accident caused by an object belonging to a third party (a flowerpot falling from a balcony, a tile or a tree branch falling, etc.); a fall due to poor road maintenance or a lack of signage; a fall in a place open to the public (store, administration, etc.); an incident in the playground or during a physical education and sports session; a medical accident (medical or diagnostic error, nosocomial infection, etc.); an injury caused by a defective or toxic product (device, equipment, prosthesis, medication, food, etc.), etc.

Logically, to report an accident, the third party (and/or their insurer) must be identified. Whether or not the perpetrator acknowledges liability changes nothing for you. In addition, the damage may have occurred in France or abroad.

When and how to report bodily injury caused by a third party ?

The procedure can be carried out in four different ways:

from your Ameli account, under “My procedures/Report bodily injury caused by a third party/Report an accident” ; in a few clicks, on Simplified Procedures where you just need to provide information on the victim and the circumstances of the accident (filling time 5 min); by telephone by dialing 36 46 from Monday to Friday from 8:30 a.m. to 4:30 p.m. (free service + cost of a call); by mail by sending to your primary health insurance fund (CPAM) the completed simplified declaration form for bodily injury caused by a third party (Cerfa no. 16341-01).

You can complete the declaration at any time. There is no maximum deadline, but by making your declaration as soon as possible, you facilitate the processing of the appeal.

And for your reimbursements, what does that change? ?

For you, nothing: you will be reimbursed according to the usual conditions, rates and deadlines by Health Insurance, regardless of your possible share of responsibility in the accident. Reporting the accident may, however, speed up your own compensation from the insurer.

As with health care reimbursements, the disability pension or permanent disability pension in the event of a work accident will, depending on the severity of the after-effects following the accident, be paid according to the usual conditions, rates and timeframes by Health Insurance. In the event of death following an accident caused by a third party, beneficiaries may request the allocation of a death benefit.

Please note : also remember to inform your doctor and other healthcare professionals (pharmacist, physiotherapist, nurse, etc.) that you consult following this accident. They will check the box “Accident caused by a third party” on your treatment sheet and indicate the date of the accident.

For more information: If your injury is caused by a third party