Facts

The complainant, a delivery van driver born in 1984, fell from a truck ramp (height approx. 120 cm) in a warehouse on 8 August 2019 and sustained a displaced multi-fragmentary clavicle fracture on the right side, right-sided rib fissures, a parietal-occipital laceration on the right side, and a mild traumatic brain injury (TBI) Grade I. He was employed by [B. GmbH] and was compulsorily insured against accidents with the Swiss Accident Insurance Fund (Suva).

The Suva initially provided the statutory benefits (medical treatment, daily allowance). In a letter dated 11 June 2021, it informed the complainant that further medical treatment was no longer necessary as no significant improvement in his state of health could be expected. The benefits were discontinued as of 30 June 2021. In a decision dated 17 June 2021, the Suva also denied entitlement to a disability pension due to the absence of a degree of disability qualifying for benefits and to compensation for loss of integrity due to the absence of a lasting substantial impairment. In justification, it stated that the complainant was capable of performing light to medium-stress full-time work that did not involve risk of falling or require special support function of the right hand. The complainant’s appeal was dismissed in a decision dated 12 October 2021.

The Social Insurance Court of the Canton of Zurich dismissed the appeal lodged against this in a judgment dated 31 August 2022. The complainant now applies to the Federal Supreme Court for the annulment of the lower-instance judgment and for the retroactive granting of statutory benefits (medical treatment, daily allowance, possibly partial pension and compensation for loss of integrity) as well as vocational integration measures. Alternatively, he requests that the matter be referred back for reassessment and for the ordering of a multidisciplinary expert opinion.

Considerations

The Federal Supreme Court examines the appeal in public law matters for violations of law pursuant to Art. 95 and 96 FSCA. It applies the law ex officio (Art. 106 para. 1 FSCA), but is limited to the submissions made, unless there are obvious further legal deficiencies. In social insurance proceedings, the Federal Supreme Court is not bound by the lower-instance court’s findings of fact (Art. 97 para. 2 and Art. 105 para. 3 FSCA).

Causal link and entitlement to benefits: Entitlement to accident insurance benefits requires a natural and adequate causal link between the accident event and the damage. The natural causal link exists if the damaging event cannot be disregarded without the health impairment ceasing to exist. The burden of proof for the causal link lies with the insured person, while the accident insurance must prove the absence of the causal link. In cases of psychological suffering, a special adequacy review is required, particularly if organic causes are absent. Adequacy is assessed based on the evident course of events and other accident-related criteria (BGE 134 V 109 para. 2.1).

Case closure and significant improvement: Case closure with discontinuation of benefits is compliant with federal law if no significant improvement in the state of health can be expected from further treatment. The term “significant” requires a material increase in earning capacity. The lower-instance court relied on medical expert opinions that did not expect any significant improvement from further treatment. The assessment of medical opinions must meet strict requirements; if doubts arise regarding their reliability, additional clarifications must be carried out. In the present case, all standard pain therapy measures had been exhausted, and further interventions (e.g., removal of material) would not have resulted in any significant improvement. The recommendation of psychotherapy due to a pre-existing accident-related post-traumatic stress disorder does not change the outcome, as this is not causally linked to the accident.

Organic accident consequences and psychological complaints: The complainant argued that a mild traumatic brain injury and neuropathic pain had not been sufficiently clarified. However, the Federal Supreme Court confirmed that the imaging examinations (CT) carried out showed no intracranial trauma consequences and that the initial headaches subsided quickly under…