Câu hỏi 20. Điều kiện hưởng và thủ tục hưởng bảo hiểm tai nạn lao động, bệnh nghề nghiệp?

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 Khi NLĐ xảy ra tai nạn lao động sẽ được hưởng chế độ tai nạn lao động, bệnh nghề nghiệp theo quy định pháp luật khi đáp ứng đủ các điều kiện và thực hiện thủ tục như sau:

  1. Điều kiện hưởng chế độ tai nạn lao động, bệnh nghề nghiệp

Theo quy định pháp luật, NLĐ hưởng trợ cấp tai nạn lao động, bệnh nghề nghiệp hằng tháng hoặc một lần được tính trên cơ sở tổng các mức tiền lương làm căn cứ đóng vào quỹ tai nạn lao động, bệnh nghề nghiệp của tất cả các HĐLĐ tại thời điểm xảy ra tai nạn lao động, bệnh nghề nghiệp, nhưng không quá mức tối đa theo quy định của pháp luật BHXH[1].

Cụ thể, NLĐ tham gia bảo hiểm tai nạn lao động, bệnh nghề nghiệp sẽ được hưởng chế độ tai nạn lao động khi đáp ứng đủ các điều kiện sau đây[2]:

  • Bị tai nạn thuộc một trong các trường hợp sau đây:
  • Tại nơi làm việc và trong giờ làm việc, kể cả khi đang thực hiện các nhu cầu sinh hoạt cần thiết tại nơi làm việc hoặc trong giờ làm việc mà BLLĐ và nội quy của cơ sở sản xuất, kinh doanh cho phép, bao gồm nghỉ giải lao, ăn giữa ca, ăn bồi dưỡng hiện vật, làm vệ sinh kinh nguyệt, tắm rửa, cho con bú, đi vệ sinh; hoặc
  • Ngoài nơi làm việc hoặc ngoài giờ làm việc khi thực hiện công việc theo yêu cầu của NSDLĐ hoặc người được NSDLĐ ủy quyền bằng văn bản trực tiếp quản lý lao động; hoặc
  • Trên tuyến đường đi từ nơi ở đến nơi làm việc hoặc từ nơi làm việc về nơi ở trong khoảng thời gian và tuyến đường hợp lý.
  • Suy giảm khả năng lao động từ 5% trở lên do bị tai nạn nêu trên;
  • Tuy nhiên, cần lưu ý rằng NLĐ sẽ không được hưởng chế độ do Quỹ bảo hiểm tai nạn lao động, bệnh nghề nghiệp chi trả nếu tai nạn xảy ra do một trong các nguyên nhân sau đây:
  • do mâu thuẫn của chính nạn nhân với người gây ra tai nạn mà không liên quan đến việc thực hiện công việc, nhiệm vụ lao động;
  • do người lao động cố ý tự hủy hoại sức khỏe của bản thân; và
  • do sử dụng ma túy, chất gây nghiện khác trái với quy định của pháp luật.

 

  1. Thủ tục hưởng chế độ tai nạn lao động
  • Việc giải quyết hưởng chế độ bảo hiểm tai nạn lao động được thực hiện như sau[3]:
  • NSDLĐ nộp hồ sơ cho cơ quan BHXH trong thời hạn 30 ngày, kể từ ngày nhận được đầy đủ hồ sơ hưởng chế độ bảo hiểm tai nạn lao động; và
  • trong thời hạn 10 ngày, kể từ ngày nhận đủ hồ sơ, cơ quan BHXH có trách nhiệm giải quyết hưởng chế độ bảo hiểm tai nạn lao động; trường hợp không giải quyết thì phải trả lời bằng văn bản và nêu rõ lý do.
  • Hồ sơ hưởng chế độ bảo hiểm tai nạn lao động bao gồm[4]:
  • Sổ BHXH;
  • Giấy ra viện hoặc trích sao hồ sơ bệnh án sau khi đã điều trị tai nạn lao động đối với trường hợp nội trú;
  • Biên bản giám định mức suy giảm khả năng lao động của Hội đồng giám định y khoa; và
  • Văn bản đề nghị giải quyết chế độ tai nạn lao động.

Tùy từng trường hợp cụ thể, cơ quan bảo hiểm có thể yêu cầu bổ sung thêm hồ sơ trước khi thực hiện giải quyết chế độ bảo hiểm tainạn lao động.

[1] Điều 5.1 Nghị định 37/2016/NĐ-CP ngày 15/05/2016

[2] Điều 45 Luật an toàn vệ sinh lao động 2015

[3] Điều 59 Luật an toàn vệ sinh lao động 2015

[4] Điều 58 Luật an toàn vệ sinh lao động 2015

583 Bình luận

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