Ordinance on Daily Sickness Benefit Insurance (Daily Benefit Insurance Ordinance, KTV-VO) (KTV-Verordnung, KTV-VO) - Purpose (KTV-VO)

1. In the event of continued incapacity to work due to illness, the Sickness Daily Allowance Insurance (SDAI) provides benefits in accordance with the provisions of this regulation.

1. In this regulation, the following terms are defined as

a) Insured: the employees and former employees according to Article 3, paragraph 1 and paragraph 2 of the Personnel Act (PA);

b) Employers: the employers according to Article 3, paragraph 1 and paragraph 2 PA;

c) KTV Administration: the Personnel Office (PO).

1. Commencement of Insurance Coverage

a) Insurance coverage begins on the first day of an indefinite employment relationship or one that is limited to more than three months;

b) Insurance coverage begins on the first day of the fourth month for an employment relationship limited to three months or a shorter period, if it has lasted more than three months.

2. Termination of Insurance Coverage

Insurance coverage ends on the last day of the employment relationship, but no later than the day pursuant to Article 15 paragraph 1 PG.

3. Subsequent Inability to Work

A later occurring inability to work is neither insured nor insurable with the KTV.

1. In the event of incapacity to work due to illness that has occurred during the period of insurance coverage, there is an entitlement to benefits under the KTV in accordance with the provisions set out below.

2. During the employment relationship, the benefits are owed to the employer, and thereafter to the former employees.

3. The incapacity to work is assessed by the extent to which the official duties can be fulfilled. From the 545th day of continued payment of wages or after the end of the employment relationship, consideration is also given to the extent to which reasonable work in other professions can be performed.

4. Article 3 and Article 6 of the Federal Act on the General Part of Social Insurance Law apply mutatis mutandis.

1. For each calendar day for which there is an entitlement to benefits, a daily allowance is granted, calculated according to the following formula: Insured Salary x 12 / 365.

2. The insured salary corresponds to the last monthly salary before the commencement of the benefit period pursuant to Article 6 or, in the case of fluctuating employment, one twelfth of the salary paid in the preceding 365 days. If the annual salary exceeds the maximum of the highest salary class, the insured salary equals one twelfth of this maximum at the start of the benefit period pursuant to Article 6.

3. The insured salary includes the pro rata 13th-month salary as well as permanent monthly allowances such as special social allowances, night, weekend, and shift allowances, or functional allowances, except for child and education allowances or family allowances.

4. One-time payments, such as performance and spontaneous bonuses, support contributions for third-party childcare, or sustainability allowances, are not included in the insured salary.

5. In cases of intentionally self-induced incapacity for work, the daily allowance is reduced to half, unless the insured salary has already been correspondingly reduced.

6. During partial incapacity for work and when adjusting the salary due to changes in employment scope agreed upon before the onset of incapacity for work, the daily allowance is adjusted accordingly. Other salary adjustments are not considered.

1. Benefits are provided from the day following the 365th day of continued salary payment. If the employment relationship ends earlier, benefits are provided early from the day following the last day of salary payment. The duration of salary continuation is determined by Article 39 of the Personnel Regulations.

2. The duration of benefits is determined according to the following principles

a) it is a maximum of 365 days, plus the number of days before reaching the 365th day of salary continuation, for which benefits are provided early according to paragraph 1;

b) during partial incapacity for work, the relevant days count as whole days;

c) in the case of renewed incapacity for work due to illness (relapse), the previous benefit duration is taken into account, unless there was full working capacity for at least six months without interruption;

d) during an unpaid leave, no benefits are provided, however, the relevant days are credited to the benefit duration.

3. The duration of benefits ends at the latest

a) on the 90th day after the end of the employment relationship if the employment relationship is terminated during the probationary period;

b) after the expiration of twice the duration of a fixed-term employment relationship according to Article 6 paragraph 2 or Article 15 paragraph 4 PG, but no later than the 180th day after the end of the employment relationship if it ends due to the fixed-term nature or, in the case of premature termination of the employment relationship, would end;

c) on the day the employment relationship ends due to retirement in accordance with Article 15 PG, or, in the case of premature termination of the employment relationship, would end;

d) on the last day of the month of death if the insured person dies.

1. Monetary benefits with the same purpose, provided by mandatory insurance for the same period, shall be offset against the benefits of the KTV.

2. If the compulsory accident insurance, disability insurance (IV), the pension fund Graubünden, or the military insurance subsequently grants a pension due to illness or accident, the canton may demand from the insurer that the pension be paid to the canton up to the amount of its advance payment, or to the extent for the benefit of the KTV, in which the canton provided benefits of the KTV during the period for which the pension is retroactively paid.

1. Claims for benefits must be asserted by the employer by the 300th day of continued wage payment or by the insured persons by the first day after the end of the employment relationship.

2. Upon asserting a claim, the KTV administration must be provided with the information and evidence necessary to clarify the entitlement to benefits.

3. Unasserted claims for benefits shall expire two years after the day to which they pertain.

**1. Employers and Insured Individuals are obligated within the bounds of reasonableness to:**

a) promptly submit the relevant medical certificates to the KTV administration by the 30th day following the onset of a work incapacity and subsequently on an ongoing basis;

b) undertake all efforts to reduce the duration and extent of a work incapacity by promoting the recovery and (re)integration of the insured persons into a work process, specifically through timely and professional initiation, implementation, and active support of absence and rehabilitation management, integration advice, and coaching;

c) seek support and benefits from third parties as early as possible according to Article 7, particularly by reporting for early detection and filing claims for benefits with the IV within six months from the onset of the work incapacity;

d) inform the KTV administration promptly and continuously of all circumstances relevant to the examination, assessment, and duration of benefits, such as the insured salary, changes in work incapacity, unpaid leave, findings and decisions of the IV, benefits from third parties according to Article 7, salary adjustments according to Article 5 paragraph 6, or termination of the employment relationship;

e) comply with the orders and recommendations of the KTV administration, particularly to undergo a medical examination by a trusted physician, as well as the instructions from medical professionals, rehabilitation or case management, integration advisors, and coaches;

f) provide the KTV administration with further relevant information and documents upon request;

g) instruct rehabilitation or case management, integration advisors, and coaches acting on their behalf to provide the KTV administration with relevant information and documents upon request.

1. If the employers or insured persons fail to fulfill their obligations under this regulation, benefits may be temporarily suspended or reasonably reduced and reclaimed, and the responsible party must indemnify the KTV for any additional expenses incurred as a result.

1. The KTV Administration ensures the implementation of the KTV. It

a) supports employers and insured individuals in the assertion of benefits and the fulfillment of their obligations under this regulation;

b) reviews the asserted claims and disburses the benefits;

c) takes or initiates measures necessary to clarify the asserted benefit claims and to reduce incapacity for work, such as medical examinations by trusted physicians, coaching, and case management;

d) collects premiums, third-party benefits, as well as reimbursement and compensation claims in favor of the KTV Fund, or offsets them against future benefits;

e) reports annually to the Department of Finance and Municipalities (DFG) on the income and expenditures of the KTV Fund;

f) proposes an adjustment of the premiums to the DFG when deemed appropriate according to Article 12, Paragraph 2;

g) may apply for an adjustment of the cost reimbursement for the administration to the DFG when the condition under Article 14, Paragraph 2 is met;

h) may issue directives, particularly when it appears necessary to clarify the obligations of employers and insured individuals.

1. For the implementation of the purposes of the KTV, an independent fund exists within the special assets of the canton (KTV Fund).

2. To ensure the purposes of the KTV and an appropriate and balanced premium burden, the assets of the KTV Fund shall not be less than the equivalent of, and not more than twice, the benefits that have been paid on average over the last five years.

1. As long as the insurance coverage according to Article 3 exists, employees are required to pay premiums.

2. The premiums finance the benefits. They are determined based on a uniform and, where possible, cost-covering contribution rate established by the DFG for the calendar year.

3. The premiums are levied on the relevant salary in accordance with federal legislation on old-age and survivors' insurance. In this context, Article 6 paragraph 2 letter b of the Ordinance on Old-Age and Survivors' Insurance is disregarded with respect to the benefits of the KTV. If the annual salary exceeds the maximum of the highest salary class, no premiums are owed on the portion exceeding it.

4. Employers deduct the premiums monthly or, in the case of premiums related to a period of unpaid leave, in the following month from the employees' salaries and transfer the total amount per calendar year to the KTV by January 31 of the following year.

1. For the administration of the KTV, the PA shall receive 150,000 Swiss Francs annually from the KTV fund.

2. If the annual administrative costs are significantly lower or higher, the DFG may reasonably decrease or increase the amount mentioned in paragraph 1.

1. Employers are obligated to indemnify the collective bargaining agreement (CBA) for benefits that were disbursed early under Article 6, Paragraph 1, as well as for any additional expenses caused by the premature termination of the employment relationship.

2. Indemnification under Paragraph 1 is waived if it can be credibly demonstrated that

a) the employment relationship ended due to a fixed-term contract under Article 6, Paragraph 2 of the Public Service Act;

b) there was a legal ground for termination and the statutory notice periods and dates were observed;

c) the insured person voluntarily terminated the employment relationship and the statutory notice periods and dates were observed.

3. Benefits that were unjustly obtained or disbursed must be reimbursed.

1. In the event that no agreement is reached in disputes concerning matters regulated by this ordinance

a) In cases involving employers as referred to in Article 3, Paragraphs 1 and 2, Letter b of the Personnel Act (PG) on one side, and the KTV administration on the other, the government makes the final decision;

b) In all other cases, upon request or ex officio, the KTV administration issues a contestable order.

1. Claims for Benefits and Claims for Bonus Payments, Claims against Third Parties, Claims for Reimbursement and for Damages shall be Governed

a) by the old law, if the circumstances occurred before the coming into force of this regulation;

b) by the new law, if the circumstances occurred after the coming into force of this regulation.