% vol = 17 number = 1 prevlink = 40 nextlink = 49 titolo = "BURN DAMAGE AND LAWS REGARDING INDUSTRIAL INJURIES: CLINICAL AND MEDICO-LEGAL ISSUES" volromano = "XVII" data_pubblicazione = "March 2004" header titolo %>
SUMMARY. This paper focuses on data regarding burn accidents for which compensation was awarded by INAIL (Istituto nazionale per l’assicurazione contro gli infortuni sul lavoro, i.e. National Institute for Insurance against Industrial Accidents). This is the public agency in Italy that deals with compulsory insurance against industrial accidents and occupational diseases in industry, trade, and craft trades. The data refer to the period 1994-2000. It is important to stress that the cases mentioned are those for which compensation was actually paid - they do not represent the total number of accidents in the work environment. New regulations recently came into effect in Italy in the year 2000: the new system provides for three compensation procedures. These consist of a disability chart (385 entries, arranged by number and in relation to the functional systems involved); a biological damage compensation chart (regarding factors such as the gravity of the damage, chronological age, and sex; and a coefficient chart (to compensate for the financial loss caused by disabilities of at least 16%). However, this method for the overall evaluation of burn-related injuries, from scar sequelae to other outcomes of the burn disease, is inadequate in the light of what is now known about thermal trauma. We may say this because, if strictly applied, the procedure would mean that the highest percentage degree of disability acceptable for compensation would be only 30%. This score (equivalent to one-third of psychological and physical integrity) is not a fair assessment of the damage represented by face disfigurement due to third-degree burns or by injuries in 80% of the body surface area. Our suggestion is to reform the charting system by introducing, alongside scar entries, various other separate factors allowing an assessment of burn sequelae and calculating the total disability percentage by means of a proportional formula based on single damage factors. To this end, it might be useful to formulate a weighted estimate by analysing Italian and other national evaluation standards and by comparing international manuals and the current INAIL chart.
INAIL (Istituto nazionale per l’assicurazione contro gli infortuni sul lavoro, i.e. National Institute for Insurance against Industrial Accidents) is the public agency in Italy that deals with compulsory insurance against industrial accidents and occupational diseases in industry, trade, and craft trades. Seamen and agricultural and forestry workers are covered respectively by the Casse Marittime (Mariners’ Insurance Fund) and by ENPAIA (Ente Nazionale di Previdenza e Assistenza degli Impiegati dell’Agricoltura (National Board for Social Security of Agriculture Employees). State employees and other State-protected categories are covered by INAIL, under a special agreement.
From a juridical point of view, the parties involved in the insurance contract are the following: the insurer (the State, represented by INAIL), the policy-holder/contractor (the employer), and the insured (the employee). The three parties become two in the case of the self-employed (policy-holder = insured party) and civil servants (insurer = policy-holder), but the insurance maintains its compulsory character.
The industrial injury law has evolved over the period between 1883 and 1965 (Consolidated Text 1124/65), when the current provisions were issued. The provisions have been widely amended through the introduction of new laws and rulings, and in 2000 the concept of biological damage was introduced. Prior to this, this concept was only considered in the realm of civil liability.
The following parties are entitled to INAIL coverage: employees (i.e. manual workers of all kinds, clerical workers engaged in manual activities, outdoor workers and domestic servants, and other categories listed in the Consolidated Text), students and teachers at schools of all grades, prison inmates and convicts engaged in sheltered employment, clergymen, self-employed persons (craftsmen), and foreign workers (Consolidated Text, Article 2).
The activities covered include handicrafts and work requiring the use of machines, as listed in Article 1 of the Consolidated Text (objective requirements).
The insurance comes into effect when the insured party falls victim to an industrial accident or an occupational disease.
The insurance covers accidents specified in the Consolidated Text determined by a violent cause, occurring at the workplace, and having specific consequences: death, permanent disability, or a temporary disability (with total incapacity for the specific job involved) lasting more than three days.
The accident does not need to take place at the workplace or during working hours, but there must be a direct link with the activity insured.
Coverage under the Consolidated Text refers to the economic value of the insured party’s working capacity, this capacity being directly related to working aptitude. Working capacity is therefore synonymous with process-dependent skills, i.e. with the psychological and physical well-being necessary for the purpose of any manual activity that presents some economic advantage, regardless of the activity specifically practised by the employee or of any process-independent skills (these are however taken into account with regard to compensation for temporary incapacity).
The INAIL forensic pathologist will evaluate the percentage degree of permanent disability by carrying out health checks based on the values listed in charts 1 and 2, Consolidated Text Appendix (Articles 78 and 214), which refer respectively to the industrial and to the agricultural sector. If a disability is not listed in the charts, the loss of working ability will be determined by analogue criteria. The pathologist will always take into account any possible pre-existing injuries, whether due to industrial or non-industrial causes (Articles 79, 80, 81, 82).
Under Article 66, the services offered are the following:
The insured employee is entitled to the above:
An historic decree issued by the Constitutional Court (n. 184, 30 June 1986) introduced the concept of biological damage as a paramount item of compensation payable to the injured party under civil liability laws.
After long debate, Legislative Decree n. 38 of 23 February 2000 introduced the concept of biological damage into the INAIL indemnity system, stressing its temporary character “pending a general definition of the concept itself and of the standards that will be used to determine compensation” (Article 13, Paragraph 1).
Under Article 13 of this Legislative Decree, the concept of biological damage is provisionally described as “damage to the person’s psychological and physical integrity, subject to medical and forensic examination”, as compared with the notions of “disablement” and “impairment” cited respectively in the sentence and in the proposal advanced by ISVAP (Istituto Superiore di Vigilanza sulle Assicurazioni Private, i.e. Institute for the Supervision of Private Insurance).
The accidents covered are the same as those specified in Article 2 of the Consolidated Text, the term “disablement” being substituted for “permanent incapacity for work”.
The Decree marks the introduction of several changes:
The above points suggest that while the new regulations establish a change in the indemnity status of employees who suffer a permanent disability, the situation has remained unchanged as regards workers entitled to total temporary disability benefits, which are paid out in accordance with the procedure laid down in the Consolidated Text.
Furthermore, employees subject to temporary biological disability and permanent slight disablement (biological damage less than 6%) will not be entitled to compensation.
Death is outside the scope of the new regulations. Since biological damage is caused by an infringement of the right to health, the injured party must be alive in order for him or her to receive the benefits due. The death of an insured worker is an infringement of the right to life, which is quite a different legal concept. This explains why the regulations governing survivors’ benefits have not been affected, since these benefits are deemed to be compensation for the financial loss suffered by the survivors following the worker’s fatal accident.
The new regulation came into effect on the date of the Decree’s publication in the Gazzetta Ufficiale (Official Journal of the Italian Republic), i.e. 25 July 2000.
The new system provides for three compensation procedures:
1. Disability chart
This illustrates all compensation cases due to injuries and/or illnesses, including dynamic-relational factors. The chart comprises 385 entries, arranged by number and in relation to the functional apparatus involved. It also contains three attachments regarding the assessment of damage to hearing, sight, and breathing capacity. The main change is the introduction of cosmetic damage as one of the factors listed in the chart entries.
2. Biological damage compensation chart
This presents the compensation standards applied in relation to the biological damage percentage (from 6 to 100%). The compensation due on the basis of the percentage score is calculated without reference to the employee’s working income but taking into account factors such as gravity of damage (increase factor), chronological age (in inverse proportion to the compensation granted), and sex (women tending to live longer than men).
3. Coefficient chart
This shows the standards used to establish the compensation percentage to be taken into account when calculating the amount of supplementary annuity intended to compensate for the financial loss caused by a disability of at least 16%.
The commonest mistake made by the enforcers of the new regulations is to confuse the indemnity system with the civil law provisions that govern compensation issues.
The biological damage compensation paid out by INAIL has a social function and aims to guarantee to the worker adequate means of living, as prescribed by Article 38 of the Italian Constitution.
In contrast, civil law provisions regarding biological damage aim to compensate biological damage according to its actual extent. This means that a civil action ends with the payment of an all-inclusive amount, thereby terminating the relationship between the parties, while the social indemnity system provides for an assessment of the injured party’s state of health over time. The economic compensation is revalued in the course of time and supplemented by services of various nature (medical care, prostheses, follow-up operations, social welfare).
The following charts contain an analysis of data regarding burn accidents for which INAIL provided compensation in the period 1994-1999. It is important to bear in mind that the cases cited are those for which compensation was actually given: they do not represent the total number of accidents that occurred in the work environment (Tables I-IV).<% createTable "Table I ","Number of burn accidents for which INAIL provided compensation (1994-99)",";Year;Number of burn accidents for which INAIL provided compensation@;1994;72@;1995;72@;1996;52@;1997;29@;1998;22@;1999;20","",4,300,true %> <% createTable "Table II ","Disability range (0-10%) and temporary total disability (days)",";Year;Number of burn accidents for which INAIL paid compensation;Number of accidents and permanent disabilities (0-10%) ;Temporary total disability (days)@;1994;72;70 (0-5%);1 to 88@;1995;72;70 (0-7%);0 to 85@;1996;52;50 (0-4%);0 to 183@;1997;29;28 (0-1%);0 to 92@;1998;22;20 (0-2%);0 to 52@;1999;20;17 (0%);0 to 210","",4,300,true %> <% createTable "Table III ","Disability range (11-15 %) and temporary total disability (days)",";Year;Number of burn accidents for which INAIL paid compensation ;Number of accidents and permanent disabilities (11-15%) ;Temporary total disability (days)@;1994;72;1 (14%);120@;1995;72;0;0@;1996;52;1 (11%);287@;1997;29;1 (15%);208@;1998;22;1 (12%);0@;1999;20;0;0","",4,300,true %> <% createTable "Table IV ","Disability range (>16 %) and temporary total disability (days)",";Year;Number of burn accidents for which INAIL paid compensation ;Number of accidents and permanent disabilities (>16%) ;Temporary total disability (days)@;1994;72;1 (35%);148@;1995;72;2 (40-100%);648-711@;1996;52;1 (32%);387@;1997;29;0;0@;1998;22;1 (20%);216@;1999;20;3 (39-55%);270-397","",4,300,true %>
The violent cause of a burn accident can be classified as being of electric, electromagnetic, or thermal origin.
The overall evaluation of burn-related injuries, from scarring to other burns sequelae, is inadequate in the light of what is known about thermal trauma.
With regard to scarring, the disability chart formulated in Article 13, Paragraph 2 of Ministerial Decree presents the following entries (Table V):<% createTable "Table V ","INAIL impairments (entries 36-37-38)",";Impairment;Percentage biological damage@;Skin scars, not affecting face and neck, dystrophic, dyschromic;Up to 5% @;Disfigured skin scars, not affecting face and neck ;Up to 12% @;Skin scars also affecting face and neck, and depending on extent and overall facial damage causing general disfigurement;Up to 30%","",4,300,true %>
Apart from their frequent association with functional alterations, scar sequelae - by their very nature - represent one of the main problems posed by burn injuries.1 They constitute a pathology of their own secondary to the thermal trauma, affecting the patient’s functional and psychological recovery.
The clinical behaviour of burns sequelae is extremely variable. If the evolutionary phase and the time necessary for their stabilization are not accurately predicted, the clinical course presents prognostic problems. The assessment of their actual gravity is difficult and in some cases impossible.
The various clinical and biological categories that classify scars as hypertrophic, retracting, hypertrophic-retracting, and atrophic2 indicate the existence of different clinical statuses that are subject to evolution in time.
The behaviour of the various clinical types is extremely variable, often in the same patient.
The extent of the lesion is another very important factor. Scars covering a wide surface, even when not affecting the face and neck, are a manifestation of cutaneous damage that is much more significant than a simple bridle scar and causes far more serious problems. These include frequent blistering, with the subsequent destruction of the epithelium in wide areas, pyoderma, and the development in time of atrophies liable to develop into tumours.
Other important factors are the discomfort suffered by the patient due to modification in sweating, dysaesthesia, and the possible necessity of surgical repair of ruptures of cicatricial plates or bridle scars.3
Apart from scarring, other clinical elements need to be considered, e.g. the effects on unburned areas due to prolonged stay in bed and enforced immobility, or to contiguous scars and intra- and extra-articular ectopic calcification affecting the working of the joints.
The extreme uncertainty of prognosis is further increased by the varying nature of individual responses, which is the first and most important negative factor against correct and precise assessment of the damage, with the result that the assessment system we have considered is inadequate as regards actual reality. If strictly applied, it would lead to the assumption that the highest percentage degree of acceptable disability would be only 30%.
This score (equivalent to one-third of psychological and physical integrity) is not a fair assessment of the damage represented by the disfigurement of the face caused by third-degree or 80% BSA burns.
With regard to the burn illness and its consequences, it is hardly necessary here to remind the reader how this pathology affects the organs and body systems and how difficult it is to estimate its actual duration, even after clinical recovery.
Even though a disfigured face or damaged hands represent a very serious disability, burn victims cannot simply be regarded as “bearers of scars”: they are individuals suffering from alterations of their integument, limited joint functionality, organ deficiency, and social and affective repercussions.
For this reason, it is necessary in our opinion to proceed as follows:
To this end, it might be useful to formulate a weighted estimate by analysing Italian and other national evaluation standards and by comparing international manuals and the current INAIL chart.
RESUME. Cette étude considère les données pour ce qui concerne les brûlures accidentelles compensées par INAIL (Istituto nazionale per l’assicurazione contro gli infortuni sul lavoro - L’Institut National pour l’Assurance contre les Accidents Industriels). Cet Institut est l’organisme public en Italie qui s’occupe de l’assurance obligatoire et des maladies professionnelles dans l’industrie, le commerce et l’artisanat. Les données concernent la période 1994-2000. Il est important de souligner que les cas cités sont ceux pour lesquels la compensation a été effectivement payée - ils ne constituent pas le numéro total des accidents dans l’environnement industriel. Le nouveau règlement récemment entré en vigueur en Italie (2000) prévoit trois procédures de compensation. Celles-ci sont une carte des incapacités (385 articles, disposés par numéro et en rapport aux systèmes fonctionnels intéressés); une carte pour la compensation du dommage biologique (pour ce qui concerne les facteurs comme la gravité du dommage, l’âge chronologique et le sexe; et une carte des coefficients (pour compenser la perte économique causée par une invalidité d’au moins 16%). Pourtant, cette méthode pour l’évaluation globale des lésions dues aux brûlures, depuis les simples séquelles cicatricielles jusqu’aux complications de la maladie brûlure, est insuffisante si l’on considère les connaissances les plus récentes en matière des traumatismes thermiques. Il est possible de faire cette observation parce que l’application rigoureuse de la procédure signifierait que le degré le plus élevé d’invalidité acceptable pour la compensation serait seulement 30%. Ce pourcentage (l’équivalent d’un troisième de l’intégrité psychologique et physique) ne représente pas une juste évaluation du dommage constitué par un défigurement causé par des brûlures de troisième degré ou par des lésions dans 80% de la surface corporelle. Nous proposons une modification du système susmentionné des cartes avec l’introduction, à côté des évaluations des séquelles cicatricielles, d’autres facteurs séparés qui nous permettent d’évaluer les séquelles des brûlures et de calculer le pourcentage de l’invalidité définitive moyennant une formule proportionnelle basée sur des facteurs individuels de dommage. A cette fin, il pourrait être utile de formuler une évaluation pondérée à travers une analyse des standards italiens et d’autres pays et une comparaison entre les manuels internationaux et l’actuelle carte INAIL.