¿Qué debe valorarse en los daños corporales o las personas lesionadas en los seguros?
Circulábamos tranquilamente por una avenida cuando de repente un despistado se saltó un STOP. Nos colisionó contra el lado del conductor y nos produjo daños corporales. En el coche íbamos toda la familia: mi madre de 76 años, mi esposa de 47 años, mis dos hijos, de 10 y 14 años y yo, que tengo 50.
Desgraciadamente mi madre falleció por culpa de las lesiones. Mi esposa quedó parapléjica y yo he quedado cojo de una rodilla. Por suerte mis hijos se recuperaron perfectamente al cabo del tiempo. Fue un auténtico calvario. Entre la recuperación, las aseguradoras, los abogados y los peritos quedamos “mareados”. Bastante desgracia tuvimos que además parecía un “mercadeo”. La verdad es que algo así no te interesa hasta que no sufres el accidente. Estás totalmente desorientado y cada uno dice la suya. ¿Cómo funciona realmente todo esto?
La asistencia sanitaria
Cuando sufrimos un accidente nos atienden los servicios de urgencia, los bomberos, nos trasladan en ambulancia, helicóptero o el medio que sea. Pueden realizarnos intervenciones quirúrgicas, curas, rehabilitación, medicarnos, visitas médicas, etcétera. Nos están asistiendo para que sanemos totalmente o, en caso de no ser posible debido a la magnitud de las lesiones, se estabilicen nuestras secuelas. Que se estabilicen las secuelas significa que si hemos perdido un miembro, hemos quedado cojos o sea cual sea el impedimento físico y/o psíquico, hemos perdido esa parte funcional que no se recuperará jamás.
Pues a TODOS los gastos incurridos desde el accidente hasta la total sanación o estabilización de las secuelas de las personas se denominan GASTOS DE ASISTENCIA SANITARIA.
De todos estos gastos se hace cargo la aseguradora del vehículo “CULPABLE”, pero podría darse el caso donde la culpabilidad del vehículo no quedara clara y ninguna aseguradora quisiera hacerse cargo de los gastos de asistencia sanitaria hasta que no se resolviera la responsabilidad del asunto. Para que los conflictos entre aseguradoras no afecten a las víctimas dejándolas desatendidas, la administración española reguló un convenio para las aseguradoras a modo que cada seguro se ocupe de costear los gastos de asistencia sanitaria de los ocupantes de su vehículo, y una vez esclarecidos los hechos y responsabilidades, los seguros ya se recobrarán las cantidades entre ellas si es preciso. Así se protege a las víctimas intentando no dejarlas desamparadas por asuntos administrativos entre los seguros.
La atención sanitaria a las víctimas de accidentes es un derecho de éstas y una obligación de los seguros. Las prestaciones de los servicios sanitarios (rehabilitación, intervenciones quirúrgicas, consultas médicas, prescripciones,…) pueden darse indistintamente en cualquier centro sanitario público o privado. La víctima puede escoger libremente el centro que considere más oportuno con cargo íntegro al seguro.
Los centros sanitarios, públicos o privados, pueden tener convenios de tarifas por facturación de sus emolumentos por la prestación de servicios con las aseguradoras.
Valoración de los daños corporales o secuelas
La amputación de un miembro (mano o pierna), lesiones medulares, politraumatismos, etcétera, son daños que producen restricciones o alteraciones anatómicas, funcionales o estética en las personas tras haber sufrido un accidente, ya sea de tráfico, laboral o durante nuestra vida cotidiana.
Al contrario de los daños materiales donde casi siempre puede repararse o reponerse el bien, en el daño corporal se intenta compensar económicamente la pérdida de capacidad física, psíquica, estética o sensorial del usuario puesto no siempre la persona queda totalmente sanada como antes del accidente.
Los peritos médicos se dedican a evaluar las limitaciones y secuelas de los lesionados una vez éstas han sanado o se han estabilizado, y así calculan las indemnizaciones correspondientes en base a unas tablas que figuran en la “Ley 35/2015 de reforma del sistema para la valoración de los daños y perjuicios causados a las personas en accidentes de circulación”, la cual se utiliza como referencia, además de valorar los afectados por accidentes de circulación, el resto de personas que han sufrido lesiones corporales tanto si es por un accidente laboral o como en nuestra vida cotidiana (que te haya caído una maceta de un balcón encima de la espalda).
Según la secuela, los peritos médicos dan una puntuación de 0 a 100 puntos, donde cada punto equivale a una cantidad de dinero determinada. A modo enunciativo, y no limitativo, te indicamos qué valoran los peritos en los casos de accidentes corporales:
- La indemnización por lesiones permanentes o secuelas
- La indemnización por lesiones temporales
- Los daños morales y psicofísicos.
- La indemnización por muerte
- Otros conceptos que deban tenerse en cuenta en cuanto a las circunstancias propias de la víctima.
- Los daños y perjuicios de circunstancias económicas, incluyendo las que afectan a la capacidad de trabajo, pérdida de ingresos de la víctima o lucro cesante.
- Las indemnizaciones a cónyuges, ascendientes o descendientes con dependencia de la víctima.
Los gastos
En los casos de lesionados los peritos también deberían tasar, a precio real a modo que el afectado no deba añadir dinero, los siguientes gastos “colaterales”:
- En caso de grandes lesionados, se deberán valorarán las reformas de la adecuación de la vivienda del lesionado, entendiendo por ello los gastos de rehabilitación domiciliaria y relacionados con la pérdida de autonomía personal.
- Los gastos del funeral, traslado, repatriación, entierro de la víctima si ésta hubiera fallecido. De igual modo se procedería si fuera un gran lesionado.
- Gastos por asistencia sanitaria futura; prótesis y ortesis previendo sus substituciones futuras por desgaste.
- Costes de ayudas técnicas y de apoyo.
- Gastos por adecuación de vehículos.
- Los gastos relacionados por la pérdida de autonomía personal.
- Gastos de ayudas de terceras personas.
- Gastos que impliquen ocuparse de menores por la imposibilidad de las lesiones así como las pérdidas de capacidad de las tareas del hogar.
- Otros conceptos que deban tenerse en cuenta en cuanto a las circunstancias propias de la víctima.
- Los gastos u honorarios del tramitador que gestione todos estos conceptos.
Los días de baja
Desde la fecha del accidente hasta la total sanación o estabilización de las secuelas de la víctima pasa un tiempo. Por estos días de recuperación necesarios, los cuales el lesionado está sin trabajar, estudiar, o simplemente, sin poder hacer su vida cotidiana, debe percibir una compensación económica por cada día impeditivo.
Dependiendo de cada caso y en base a las circunstancias particulares de la víctima, los peritos calculan el importe diario en base a unos criterios objetivos para que perciba la prestación en concepto de días impeditivos o días de baja.
Este importe es independiente a que la víctima cobre otras prestaciones. Por tanto, si una persona cobra la baja laboral de la TGSS o de un seguro de pérdidas pecuniarias, el seguro culpable del accidente debe pagarle, además, por cada día de baja.
Conclusión
Para realizar una buena y justa valoración por un tema de víctimas de accidentes (tráfico, laboral, transeúnte,…) donde haya lesiones y días impeditivos, es necesario acudir a alguien que tenga una extensa experiencia, conocimientos y medios necesarios (tramitadores, peritos y abogados) para poder evaluar todos los aspectos a tener en cuenta para resolver el asunto de manera satisfactoria dentro de la desgracia que comporta haber padecido el siniestro.
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