"HIGHWAY TO HEALTH":
A FRENCH LOOK AT THE U.S. HEALTH CARE REFORM
(1st PART)

Cet article (en deux parties) est la version longue d'une conférence donnée à la Columbia University de New York le 21 septembre 2009, sur la réforme de l'assurance maladie aux Etats-Unis où le débat relatif à la création d'une assurance publique et obligatoire fait rage.

Les systèmes français et américain sont comparés autour des axes majeurs de la réforme que le président Obama défend avec pugnacité, en particulier la création d'un National Insurance Exchange où régnerait enfin une libre concurrence sur le marché de l'assurance santé, propice à une baisse des primes. La prohibition de la sélection médicale (medical underwriting), qui atteint des sommets, ou l'institution de crédits d'impôt (tax credits) finançant l'acquisition d'une couverture santé sont directement inspirés du système français.

Les chiffres donnent à eux seuls le vertige, qu'il s'agisse du nombre d'Américains dépourvus de toute couverture maladie (plus de 45 millions), du montant écrasant des franchises (deductibles) et des reste-à-charge (out-of-pocket costs) ou des dépenses de santé de l'Etat fédéral (16% du PIB), en croissance exponentielle. Le poids de l'idéologie libertarienne et individualiste au coeur de la Nation américaine est non moins frappant comme en témoigne l'argument obsessionnel de la "médecine socialisée" (socialized medicine).



INTRODUCTION

1. – There is no doubt that the proposed reform of the American health care system is an inflammatory and divisive issue in the U.S. The question of health care reform heated up even more this summer. Former U.S. President Bill Clinton – and his wife Hillary – were unsuccessful in their 1994 attempt to establish universal health care for all Americans. President Obama has learned the political lessons of this failure. While he has clearly made health care reform one of his top priorities, he did not deliver a bill drafted in secret to the lawmakers as a “fait accompli” but instead articulated the broad principles and left the details to Congress.

The risk is as great as the plan is ambitious: while the economic downturn is now favorable to a reform that the majority of Americans - at least before the summer - were in favor of, opponents of Barack Obama would like nothing more than to hand him a stinging political defeat on this issue. A defeat on health care would be particularly sweet given that President Obama has already presented the America’s Affordable Health Choices Act of 2009 (the “AAHC”) as the landmark act of his presidency, and that there is a Democratic majority in the House of Representatives and Senate. The AAHC is thus a strategic target, even before assessing the need for health care legislation in America.

2. – It would seem, however, that the current health care situation in the U.S. cannot be allowed to continue; the numbers speak for themselves: more than 45 million Americans (16 % of the population) do not have health insurance (it is estimated that 65.7 million people will be uninsured in 2019), and almost 100 million people are under-insured (and sometimes in almost as dire straits as those who are uninsured) because of an inadequate coverage. This enormous void conceals numerous disparities:

-          Disparities related to socioeconomic status: the unemployed, whose numbers are skyrocketing due to layoffs brought about by the challenging economic climate, lose their health care coverage entirely unless they can enroll in Medicaid[i];  self-employed individuals are worse off than civil servants or employees who are eligible for employer-sponsored health plans - although it should be noted that employees working for small companies are in a very precarious situation[ii];

-          Geographic disparities: rural areas are both medical and insurance “deserts”; 50 million Americans living in rural areas are faced with a scant care provider network and a small number of insurance companies[iii]; more broadly, in 34 states, 75% of the insurance market is controlled by five or fewer companie, killing competition;

-          Gender disparities: women are less likely to be eligible for employer-based benefits, more widely uninsured, charged higher premiums than men; the health coverage provided to them through the individual market is inadequate (the vast majority of individual market health insurance policies do not cover maternity care!)[iv];

-          Racial, ethnic and cultural disparities[v]: racial and ethnic minorities have higher rates of deaths and higher rates of debilitating disease - such obesity, cancer, diabetes and AIDS - than Whites; limited cultural competency and limited English proficiency alter access to care and provider-patient communication (potentially on vital subjects); likewise, over 35% of all Blacks and Hispanics who do not speak English in the home do not have health insurance[vi].

3. – The reasons for this situation are complex:

-          federal laws which do not afford sufficient protection, do not guarantee universal health care[vii] and do not penalize all types of health discrimination, not least against people trying to purchase health insurance directly from insurance companies in the individual insurance market;

-          the business practices of insurance companies :

o       which charge very high deductibles and continue to raise rates;

o       medical underwriting which leads to insurers denying coverage to millions of Americans because of pre-existing conditions (even relatively minor conditions like hay fever, asthma, or previous sports injuries can trigger high premiums or denials of coverage ; it is still legal in nine states for insurers to reject applicants who are survivors of domestic violence, citing the history of domestic violence as a pre-existing condition[viii]);

o       the shameful practice called “rescission” : when a person is diagnosed with an expensive condition such as cancer, some insurance companies review his/her initial health status questionnaire and can retroactively cancel the entire policy if any medical condition was missed (even if it is unrelated, and even if the person was not aware of the condition at the time) ; coverage can also be revoked for all members of a family, even if only one family member failed to disclose a medical condition.

-          unfair practices within the healthcare industry (which keep drugs prices outrageously high, namely through anticompetitive agreements between brand name and generic drug manufacturers or through the process known as “evergreening”);

-          hospital practices in which culture and salaries are not based on performance, or “quality” of care, but rather on “quantity” of care; even though nearly 100,000 patients die each year as a result of medical errors, there are very few systems in place which evaluate the quality of care and patient safety; coordination, medical information and training for health workforce professionals are other areas that are in need of improvement;

-          finally, a very small role is given to preventive actions (in a country where cases of diabetes and obesity are rising at a staggering rate and portend huge health care costs for the future, 40 % of obese adults were not given advice on exercise or healthy eating[ix]); 96% of Medicare expenditures (i should say unsustainable expenditures: $386 billion in 2008, ) are spent on patients with multiple chronic conditions.

4. – Given these statistics, there is an urgent need to overhaul the U.S. health care system; maintaining the status quo is not an option. For a Frenchman, for whom health care is a priority, the thought of U.S. lawmakers missing out on this opportunity is quite simply unimaginable.

The future America’s Affordable Health Choices Act of 2009 (1,018 pages) that is being discussed proposes to “provide affordable, quality health care for all Americans and reduce the growth in health care spending (…).” The second aspect of his proposal is of key importance. This reform probably would not have gotten off the ground if health care spending had not witnessed such exponential growth, even sparking serious concerns among hostile Conservatives.  In a way, the 2008 financial crisis was actually beneficial for the health of Americans, even if it risks depriving the federal government of significant leverage in financing this reform (which is estimated to cost $ 900 million over ten years, or roughly the amount needed to send a manned expedition to Mars - although this is not quite as pressing…).

At any rate, U.S. policymakers are at a historic juncture: they are about to establish a National Health Insurance Exchange, that is a marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices and purchase affordable coverage.

Paradoxically, it was the United States which invented the expression “Social Security” in 1935 when Congress passed the Social Security Act of 1935, however it has yet to put in place a social security system worthy of this name which includes mandatory health insurance.

II. – AN OVERVIEW OF THE FRENCH SYSTEM

5. – In order to have a better understanding of how America’s new Health Insurance Exchange program would operate, it would be instructive to provide a brief overview of the French social security system.

France, like many other European countries (Germany in particular), has adopted the Bismarkian system. The first layer of this system consists of mandatory statutory schemes (also called base schemes). These schemes are occupational-based, meaning that there are different schemes for different categories of workers, as follows:

-          The general scheme: this is the statutory scheme which covers all salaried workers regardless of the size of their company. This scheme provides health, maternity, disability, retirement and death insurance.

-          The self-employed social scheme (régime social des indépendants or RSI): this scheme provides health, disability and death insurance for self-employed individuals. There are three categories of self-employed: shop owners, artisans and self-employed individuals who do not fall within the previous two categories such as lawyers and CPAs. They are all covered by the same health insurance plan but have different retirement plans.

-          The agricultural scheme: this scheme covers farmers and people working in the agricultural sector.

-          Finally, there are the civil servant schemes : civil servants fall into three categories in France: those who work for the state, those who work for local government and those who work in hospitals ; these individuals are covered by special schemes which, as is the case most everywhere, are extremely advantageous.

All of these schemes provide somewhat similar benefits, however the amount of contributions vary greatly from one scheme to another (civil servants have the lowest rate of contributions while the self-employed have the highest rate since they do not have an employer).

 
6. – While this mosaic of statutory schemes is wide-reaching and covers France’s entire working population, French policymakers were aware that certain individuals, such as the poor and unemployed, did not have any health insurance at all. This led to the enactment of a July 27, 1999 act which established universal healthcare coverage (Couverture maladie universelle or CMU). Now, anyone who has been legally living in France for at least three months and who is not covered by one of the mandatory schemes is automatically affiliated with the general scheme for salaried employees. Typically, there is no charge for this affiliation, however individuals who have a minimum net taxable income (roughly EUR 6,300 for a single person) are required to contribute at a rate of 8%.

If one were to compare the French and the U.S. systems, the CMU is somewhat like Medicare and Medicaid in the U.S. Like Medicare and Medicaid, the CMU is financed by the State and provides health protection to vulnerable members of the population. However, that is the only comparison that can be drawn. The CMU is free. And it is merely an alternative arrangement that is designed to ensure that no one (either a French citizen or a foreigner who legally resides in France) goes without health care. The CMU is a “safety net,” which, in principle, no worker in France needs given that health care is already provided under the mandatory schemes. This safety net serves to “catch” those individuals who passed through the first safety net - that of the base schemes.

But there is more to the French system. While these safety nets are quite encompassing, it is possible to “top up” this coverage through private insurance.

7. – Individuals can enhance the coverage offered under the mandatory, legally governed schemes by taking out private insurance. This insurance serves to supplement the benefits in kind (the reimbursement of health expenses) or benefits in cash (daily benefits paid to employees who are on sick leave) that are paid under the base schemes in the event of illness or accident. Supplementary insurance is necessary because the base schemes do not reimburse 100 % of the cost of medicine or pay 100 % of an employee’s salary if he/she is on sick leave.

In France, collective bargaining agreements are entered into at the company level, but more importantly they are entered into at the industry level, for example the banking or metalworking industry. Many of these industry-wide collective bargaining agreements require employers to set up insurance plans for their employees (and sometimes even for former company employees who have already retired). These insurance plans are funded jointly by the employee and the employer. Where the establishment of such an insurance plan is mandatory, the employees are obligated to take out the insurance and to have the contributions automatically withheld from their salary. 

It is interesting to note that the AAHC would lay down an even stricter obligation in that individuals would be responsible for obtaining and maintaining health insurance coverage; those who choose to not obtain coverage would pay a penalty of 2.5 percent of their modified adjusted gross income above a specified level. Individuals will be required to carry basic health insurance just as most states require them to carry auto insurance.

In France, self-employed individuals are given the option of taking out private insurance. If they choose to do so, they must bear the cost alone. They are thus under no obligation to take out private insurance, and many self-employed individuals make do with the coverage offered under the base scheme.

8. – 92 % of French citizens have private (supplementary) health insurance. The reason for this is that the law that enacted the CMU also established a complementary CMU (CMU-C), which is also free of charge. Even the most impoverished of individuals can thus have 100% of their health expenses reimbursed - provided that they have been informed of their rights and are able to complete the necessary administrative formalities, which is often not the case, however, for young people, the unemployed and foreigners, who very often forgo needed medical care.

In addition to the CMU-C, French lawmakers established a mechanism that can also be found in the AAHC: assistance with acquiring private insurance (aide à l’acquisition d’une complémentaire santé or ACS). In France, this consists of a tax credit of EUR 100, 200 or 400 for low-income households that is applied to the amount of their insurance premiums. The drawback is that this aid does not cover the full amount of the premium, which amounts to roughly EUR 700 per year on average.

Generally speaking, the insurance premiums paid by employers to contribute to the financing of private insurance can be deducted from their taxable profits and the employees do not have to pay income tax on these premiums (up to certain limits).

9. – Any system of heath coverage, be it a base scheme or private coverage in particular, must offer substantial tax benefits. U.S. policymakers are therefore considering setting up a tax credit for small businesses who opt to provide health coverage to their employees instead of choosing the public option, as well as affordability credits for individuals. The credits would be more generous for those who are just above the new Medicaid eligibility levels. The credits would decline with income and be completely phased out when income reaches 400 percent of the federal poverty level ($ 43,000 for an individual or $ 88,000 for a family of four). The affordability credits (like the French ACS) are designed to make insurance premiums affordable. If these affordability credits are to be successful, their amount must be sufficient, and in order for this to work, the insurance companies must not charge excessively high premiums.

On the other hand, these types of tax breaks weigh heavily on the federal deficit, which Republicans and even Blue Dog Democrats have been quick to point out. Beginning in 2009, the French government instituted caps on its infamous tax loopholes (niches fiscales), of which there are hundreds, a move that could very well be regarded as a mini revolution. The government does not wish to eliminate them entirely, however, out of fear that it will incite France’s extremely wealthy to leave the country. This would, however, be a means of providing the country with the billions of Euros that are needed to finance its public deficits. Similarly, President Obama has proposed to scale back the amount of insurance premiums that the highest-income Americans can deduct on their taxes, taking it back to the rate that existed under the Reagan years. This money would help finance the health care reform.

10. – The French system can thus be viewed as a pyramid, with the first layer consisting of the statutory schemes and private insurance comprising the second one.

The proposed reform of the U.S. health care system, on the other hand, looks more like a series of platforms. The Health Insurance Exchange would be a transparent marketplace for individuals and small employers to comparison shop among private and public insurers. The public health insurance option would be offered to individuals and small businesses with under 25 employees who would have the option of taking out private insurance (as they have been able to do up until now) or public insurance through the new public option.

Middle-sized and large businesses would be required to provide health insurance coverage: employers would have the option of providing health insurance coverage for their workers or contributing funds on their behalf. Over time, the Health Insurance Exchange would be opened to additional employers as another choice for covering their employees.

The Health Insurance Exchange, which is expected to lead to heated competition among the insurance companies, and thus lower rates, is based on a system of differing offers (private insurance or the public option) and not on cumulative, layered schemes (public and private).

Why is this case? The reason is that President Obama decided not to scrap the system and start all over again (which would lead to a single-payer system like Canada’s or France’s), but rather to build on what was already in place. However, what is in place is primarily an employer-based system that uses private insurers alongside Medicare and Medicaid plans.

At any rate, the private and public systems in both the U.S. and France will continue to exist alongside, and remain closely dependent on, one another. This interrelationship will be fascinating to study as private insurers and public insurers generally adhere to completely different philosophies.

11. – In France, private insurance (layer 2) differs from the statutory schemes (layer 1) on key points. French law has shown that public insurers can indeed co-exist alongside private insurers, even though by nature they are diametrically different. It seems, however, that there is a divide in the U.S. between public and private health care, and this antagonism results in a very strong ideological clash.

France’s supplementary insurance schemes are run by private insurers. These are either for-profit companies, such as insurance companies, or non-profit organizations (such as “mutual” insurance companies, or cooperatives, which refuse to engage in medical underwriting and defend moral values such as solidarity and ethics). They are all “companies” within the legal meaning of the term. In other words, they are subject to insurance contract law and competition law on a common, competitive market with a European dimension. European Union law has had a strong influence on the development of the rules in this area in order to foster the establishment of a single insurance market, and in particular a single market for supplementary pensions (because, as is the case for health care, there are also optional supplementary pension schemes).

The mandatory base schemes, however, are governed by social security law, and not by insurance contract law. They are managed by social security bodies which do not have the legal status of a “company” (but rather of a non-profit public service provider) and which enjoy a legal monopoly over the management of these schemes. The European Court of Justice (“ECJ”), which is the highest court in the European Union, has ruled in this respect that the organizations or offices that manage mandatory base schemes (namely pension plans) carry out services of “general economic interest” and perform an “essential social function” and thus should not be subject neither to the principle of free competition nor to the principle of freedom to provide services. In practice, if a French artisan or shop owner decides to stop making the mandatory social security contributions to his social security office and take out insurance with a private U.K. insurer (which is less costly and thus a “better deal”), he would be in violation of the law and could be ordered to pay back contributions and penalties.

This is a key point.  The European Community is not a federation of socialist States. For over 50 years it has existed as a community of States operating under a system of economic liberalism. Its pillars are the freedom of competition, the freedom to provide services, the freedom to move goods and capital, the right of establishment and the free movement of workers within a single Market of goods and services. ECJ case law has extensively interpreted these principles and is often unsympathetic to considerations of social order. Yet, it was the ECJ which took steps to protect social security schemes whose mandatory nature was threatened by free competition.

This is proof positive that a mandatory social security system is not incompatible with extreme liberal economic thinking.

12. – In France, like in other European countries, the supplementary layer (layer 2) is also highly regulated. Even though private insurers are governed by insurance contract law and free competition, insurance companies are subject to strict public policy rules. U.S. policymakers could take this approach and opt to regulate many aspects of insurance policies in order to protect the beneficiaries. To be sure, this type of regulation limits contractual freedom, but insurance companies have always abused this contractual freedom and health insurance is much too important of an issue to give them free reign.

These public policy rules stem from the Evin Act of December 31, 1989.

Perhaps the most noteworthy French rule is that which prohibits genetic testing, and more broadly, medical underwriting in group employer-sponsored plans. A private insurance company must provide coverage to all company employees (even if this means charging higher premiums) or refuse to provide any coverage at all. In other words, it’s “all or nothing.” Insurance companies cannot choose between “good” risks and “bad” risks (for example by refusing to insure older employees, smokers, obese employees, diabetics, etc). This important rule will be one of the pillars of the U.S. health care reform which proposes to do away with cherry picking and the practice of denying coverage to people who have pre-existing conditions.

What’s more, private insurance companies in France are required to provide coverage for the “after-effects of pre-existing illnesses”, for example by paying disability benefits to an employee who sustained an on-the-job accident before he took out insurance and who was subsequently declared disabled. Similarly, insurance companies must honor coverage that was acquired before an insurance contract was terminated (for example, if an accident or illness was recognized before the insurance contract was terminated, the beneficiary remains entitled to coverage for the future)

Finally, several legal sources (the Evin Act described previously, a French Supreme Court decision and a collective bargaining agreement applicable to all employees as of July 1, 2009) have established a system of portability of insurance coverage. This means that an employee who is terminated continues to remain covered by his former employer’s group insurance plan for a fixed period of time (a maximum of 9 months). At the end of this period, the insurance company must offer to maintain certain types of coverage (health expenses for example) through an individual insurance plan and cannot impose an increase in the premium of more than 50 %. These requirements have led to a host of disputes and comments over recent months in France.

The social stakes are considerable: a large number of former employees and their families find themselves in tragic situations when an accident or illness prevents them from working or renders them disabled as they very often lose their jobs after such an incident. Studies have shown that the health of unemployed people deteriorates much more than that someone who is actively employed.

In the USA, a full one in six Americans with employer-sponsored insurance in 2006 lost that coverage by 2008. Of course, the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996 limits restrictions that a group health plan can place on benefits for preexisting conditions, even in states that allow medical underwriting. Furthermore, the HIPAA provides some protection if an individuals switches from job-based group coverage to the individual market even if he has a medical condition that would make it impossible to pass medical underwriting ; to exercise the HIPAA rights, he first has to exhaust all job-based coverage available to him/her, including COBRA, which allows him to continue in his employer's plan for 18 months by paying the full cost plus 2% ; then he has to apply for an individual health insurance policy within 63 days after his old coverage ends ; every state has to make sure there is at least one individual health insurance policy available that has to accept the individuals regardless of his health status and without waiting periods for pre-existing conditions. But the protection granted by the HIPAA is crippled by complex rules and awkward distinctions (like the method of calculating “creditable continuous coverage” for the purpose of portability). Obviously, it is not efficient.

However, health insurance portability is an extremely precious benefit. It also prevents employees from staying locked into their job just to secure health coverage, and fosters the freedom of work and free movement of workers. The means of financing this new guarantee is, however, rather complex to put in place.

Le suicide au travail :

quels droits pour le salarié victime ?

Les vagues de suicides d'ingénieurs au Technocentre de Renault en 2007 et de salariés d'EdF en 2008 puis, à nouveau, chez France Telecom en 2009 invitent à aborder le phénomène sous un angle juridique. La reconnaissance de ce type de suicide comme accident du travail soulève des enjeux financiers considérables aussi bien pour les employeurs et les CPAM (qui y sont réticents) que pour les veufs et veuves des défunts (qui revendiquent cette qualification).

 1. – Une faute intentionnelle exclusive du droit à des prestations sociales ?

En droit de la sécurité sociale, ne donnent pas lieu au versement d’indemnités journalières (prestations sociales en argent destinées à compenser la perte de gain subie par l'assuré en raison de son incapacité physique de travail) « les maladies, blessures ou infirmités résultant de la faute intentionnelle de l'assuré. » (CSS, art. L. 375-1).

De la même façon, le droit des assurances (qui régit les prestations de prévoyance versées en complément de celles de la sécurité sociale, notamment dans les entreprises) décide que « l'assureur ne répond pas des pertes et dommages provenant d'une faute intentionnelle ou dolosive de l'assuré » (C. assur., art. L. 113-1).

Mais toute faute volontaire n’est pas « intentionnelle ». Une telle faute suppose « la volonté de commettre le dommage tel qu'il s'est réalisé » ([1]), c’est-à-dire la double volonté de la cause du dommage (l’acte suicidaire, par exemple) et du résultat dommageable (le décès). Or, comme l’enseigne la psychologie médicale, toute tentative de suicide ne traduit pas nécessairement la volonté d’en finir avec la vie. Le droit admet à son tour que le désespoir puisse altérer le discernement de la victime qui ne désire pas consciemment, au plus profond, s’anéantir.

La jurisprudence estime ainsi que le suicide n’est une cause d’exclusion de la garantie de l’assureur que s’il présente un caractère conscient. Tel n’est pas le cas lorsque la lucidité de la victime a été altérée par son état dépressif ([2]). Selon une vibrante formule, la faute intentionnelle n'est pas établie lorsque l'auteur de la tentative de suicide n'a pu « garder le contrôle de lui-même, son libre arbitre et son entière responsabilité [...] a agi en réaction catastrophique et sous l'empire d'une influence morbide plus forte que l'instinct vital et [...] n'avait pu délibérément envisager le préjudice qu'il pouvait causer » ([3]) (V. aussi C. assur., art. L. 132-7 : « l’assurance en cas de décès est de nul effet si l'assuré se donne volontairement et consciemment la mort au cours de la première année du contrat »).

2. – Un accident du travail ?

L'article L. 411-1 du Code de la sécurité sociale institue une présomption d'imputabilité de l'accident au travail dès lors que celui-ci est survenu « par le fait ou à l'occasion du travail, quelle que soit la date d'apparition » de la lésion corporelle ([4]). Encore faut-il que l'accident ait un lien, même ténu, avec un travail salarié : en pratique, il doit s’être produit au temps et au lieu du travail ou dans un temps et dans un lieu voisins. Mais l’hypothèse du suicide déroge de façon remarquable à cette double exigence.

En premier lieu, la qualification d'accident du travail est en principe exclue si le dommage se produit en dehors du temps de travail, notamment au cours d'une période de suspension du contrat de travail (par ex. en cas de grève, de mise à pied ou de congé légal). Toutefois, elle peut être retenue si le salarié est demeuré, malgré cette circonstance, « sous la dépendance et l'autorité de l'employeur ». Tel est le cas de la salariée victime d'une agression dans les locaux de l'entreprise alors qu'elle était en arrêt de travail, étant revenue en ces lieux parce qu’elle avait été convoquée à un entretien préalable au licenciement, « ce dont il résultait qu'au moment des faits litigieux elle était sous la dépendance et l'autorité de l'employeur » ([5]). Un arrêt notable du 22 février 2007 étend cette solution au salarié ayant commis une tentative de suicide à son domicile alors qu’il était en arrêt maladie, son équilibre psychologique ayant été gravement compromis par la dégradation continue des relations de travail ([6]). En définitive, l’accablement psychologique dans lequel se trouve enfermé le travailleur suicidaire tisse ou exacerbe un lien de dépendance vis-à-vis de son employeur qui ne s’est pas rompu (et que lui-même n’est pas parvenu à briser) après la fin de sa journée. La qualification d’accident du travail signifie littéralement que le salarié se sent poursuivi par son travail en dehors de la sphère professionnelle.

En deuxième lieu, l'accident du travail doit, en principe, survenir au sein de l'entreprise. Mais cette localisation n'a rien de décisif. Elle se borne à refléter en arrière-fond le critère du lien d'autorité qui reste prépondérant. A ainsi été qualifiée d'accident du travail l'agression subie à son domicile par le directeur d'une agence bancaire, en raison du rapport étroit existant entre cet acte et ses fonctions (il gardait chez lui les clefs de l’agence ([7])). Le travailleur à domicile est également couvert au moment de l'exécution des tâches qui lui ont été confiées par son employeur ([8]). Plus généralement, « un accident qui se produit à un moment où le salarié ne se trouve plus sous la subordination de l'employeur constitue un accident du travail dès lors que le salarié établit qu'il est survenu par le fait du travail » ([9]). L’hypothèse essentielle est, là encore, celle du salarié en congé maladie qui commet une tentative de suicide à son domicile sous l’empire d’un syndrome dépressif causé par une vive dégradation des relations de travail : en pareil cas, le lien d’autorité, loin de s’évanouir, accable le travailleur jusque dans sa sphère privée.

En somme, le suicide a la nature d'un accident du travail s’il ne résulte pas d'un « acte réfléchi et volontaire totalement étranger au travail », c'est-à-dire que le travail soit la « cause génératrice de cet acte de désespoir » ([10]).

3. – Le suicide, conséquence d’un harcèlement moral ou d’un travail pénible

Dans cette ligne, le suicide peut se voir reconnaître la nature d'accident du travail lorsqu’il est imputable au harcèlement moral de l’employeur ([11]) ou des conditions de travail pénibles ([12]). De même, le « geste de désespoir [du salarié étant] le résultat de l'impulsion brutale qui s'était emparée de lui après les remontrances qui venaient de lui être adressées par son employeur », il « s'était donné la mort dans un moment d'aberration exclusif de tout élément intentionnel » ([13]).

La qualification d’accident du travail a cependant été écartée au motif que la dégradation de l'atmosphère dans l'entreprise avait concerné tout le personnel ([14])…

À l’inverse, ne revêt pas un caractère professionnel une tentative de suicide qui puise son origine dans des difficultés privées et personnelles, et non dans l’activité professionnelle du salarié ([15]).

4. – Nouvelle lésion

Enfin, le suicide s'analyse en une « nouvelle lésion » (prise en charge au titre de la législation sur les accidents du travail) lorsqu'il est la conséquence directe de troubles neuropsychiques dus à un premier accident du travail, banal (si l’on peut dire)  mais particulièrement traumatisant ([16]).

Tel est le cas du suicide commis par un salarié, amputé lors d’un premier accident, quatre ans après sa convocation devant un tribunal pour faire reconnaître la faute inexcusable de son employeur, alors qu’il était perturbé par la perspective de cette instance au cours de laquelle sa propre responsabilité risquait d'être engagée ([17]).

Patrick Morvan

([1]) Cass. 2^e civ., 23 sept. 2004 : Bull. civ. 2004, II, n° 410 (absence de faute dolosive du salarié décédé dans l'exercice de son activité professionnelle alors qu'il avait été reconnu atteint d'une incapacité totale de travail). L'arrêt manifeste un retour du contrôle de la Cour de cassation sur cette notion qu'elle cantonne dans des limites très étroites.

([2]) CA Toulouse, 8 févr. 1995 : D. 2006, 118, obs. B. Beignier. Comp. Cass. 1^re civ., 10 oct. 1995 : Bull. civ. 1995, I, n° 345, validant une clause d'exclusion plus large (en cas de suicide conscient ou inconscient) dans un contrat d'assurance collective accessoire à un contrat de prêt.

([3]) Cass. 2^e civ., 6 janv. 1960 : Bull. civ. 1960, II, n° 8.

([4]) Cass. soc., 2 avr. 2003 : Bull. civ. 2003, V, n° 132 (vaccination contre l'hépatite B imposée au salarié par son employeur en raison de son activité professionnelle et dont il serait résulté une sclérose en plaques).

([5]) Cass. soc., 11 juill. 1996 : Bull. civ. 1996, V, n° 282.

([6]) Cass. 2^e civ., 22 févr. 2007 : JCP S 2007, 1429, note D. Asquinazi-Bailleux ; D. 2007, p. 791 ; JCP E 2007, 1431.

([7]) Cass. soc., 4 févr. 1987 : Bull. civ. 1987, V, n° 65.

([8]) Cass. soc., 18 nov. 1993, pourvoi n° 91-12.721, inédit.

([9]) Cass. 2^e civ., 22 févr. 2007, précité.

([10]) Cass. soc., 23 sept. 1982, deux arrêts : Bull. civ. 1982, V, n° 524 et 525. - V. déjà Cass. soc., 16 déc. 1968 : Bull. civ. 1968, V, n° 596 (suicide qu'aucune affection antérieure ne pouvait expliquer).

([11]) CA Riom, 22 févr. 2000 : D. 2000, p. 634.

([12]) Cass. ass. plén., 15 déc. 1972 : D. 1973, 237, note Y. Saint-Jours.

([13]) Cass. soc., 20 avr. 1988 : Bull. civ. 1988, V, n° 241.

([14]) Cass. 2^e civ., 3 avr. 2003 : RJS 7/2003, n° 938.

([15]) Cass. 2^e civ., 18 oct. 2005 : JCP S 2006, 1012, note D. Asquinazi-Bailleux.

([16]) Cass. soc., 13 juin 1979 : Bull. civ. 1979, V, n° 535. - 23 sept. 1982 : Bull. civ. 1982, V, n° 524 (comp. ibid., n° 525).

([17]) Cass. soc., 19 déc. 1991 : RJS 1992, n° 198. - Comp. Cass. soc., 7 juill. 1994, pourvoi n° 91-11.588, inédit, refusant la qualification d'accident du travail à un suicide consécutif à un accident au cours duquel la victime n'avait été que légèrement blessée et dont l'intention suicidaire était antérieure audit accident

L'arrêt rendu le 8 avril 2009 par la Cour de cassation condamne une ancienne députée qui, après la dissolution de l'Assemblée nationale en 1997, avait licencié sa collaboratrice (recrutée deux ans plus tôt en CDI) avant de la réembaucher... deux jours plus tard... en CDD d'une durée de 20 jours (un contrat dit "précaire", selon un vocabulaire politique que ne renierait pas la députée). Affectée à la campagne électorale de son employeur puis à des tâches de secrétariat et à l'organisation du fameux festival de Chabichou, la salariée continua à travailler pendant deux mois après le terme initial de son contrat de travail, sans être payée. En pareil cas, le Code du travail requalifie le CDD illégal en CDI. La condamnation était inévitable.


Cour de cassation, chambre sociale
Arrêt du 8 avril 2009

Attendu, selon l’arrêt attaqué (Rennes, 10 avril 2008), que Mme X... a été engagée sans détermination de durée le 1er décembre 1995 en qualité de collaboratrice de Mme Ségolène ROYAL, alors députée ; que licenciée le 10 mai 1997, à la suite de la dissolution de l’Assemblée Nationale, la salariée a signé avec M. Z..., mandataire financier de Mme Ségolène ROYAL, un contrat à durée déterminée la recrutant pour la période du 12 au 31 mai 1997 inclus, en qualité d’employée de secrétariat pour l’exécution des tâches de secrétariat liées aux opérations de la campagne pour les élections législatives des 25 mai et 1er juin 1997 ; qu’estimant que sa relation de travail avec Mme Ségolène ROYAL s’était poursuivie sans interruption à l’expiration du contrat à durée déterminée et que son employeur ne lui avait pas versé de salaire, la salariée a saisi la juridiction prud’homale de diverses demandes ;

Attendu que Mme Ségolène ROYAL fait grief à l’arrêt d’avoir infirmé le jugement du 15 février 1999 en ce qu’il a débouté Mme X... de ses demandes de salaires pour la période postérieure au 31 mai 1997, dit que le contrat de travail s’était poursuivi au-delà de cette date sous la forme d’un contrat à durée indéterminée, dit que la démission de Mme X... s’analysait en un licenciement sans cause réelle et sérieuse et de l’avoir condamnée à payer diverses sommes à titre de salaires et congés payés afférents, à titre d’indemnité de préavis et congés payés afférents ainsi qu’à titre de dommages et intérêts, alors, selon le moyen :

(le texte en italique ci-dessous renferme les arguments du demandeur, c'est-à-dire le "moyen" divisé ici en trois branches)

1°/ que l’arrêt de la Cour de Poitiers du 1er février 2005, non atteint par la cassation sur ce point, a jugé qu’un contrat de travail à durée déterminée a été conclu pour la période du 12 au 31 mai 2007 pour l’exécution de taches de secrétariat liées à la campagne électorale ; qu’ainsi, la cour d’appel, qui se référant à cet arrêt, a considéré qu’au delà du 31 mai 2007, Mme X... avait continué à travailler pour le compte de Mme Ségolène ROYAL aux mêmes conditions, c’est à dire pour les besoins d’une campagne électorale qui était achevée, n’a pas tiré de ses constatations les conséquences qui s’imposaient et a violé les articles L. 121-1 et L. 122-3-10 du code du travail ;

2°/ que l’existence d’un contrat de travail suppose l’exercice d’un travail effectif sous l’autorité d’un employeur ; qu’en se bornant à relever pour décider que Mme X... était liée à Mme Ségolène ROYAL par un contrat de travail à plein temps du 1er juin 1997 au 5 juillet 1997, puis à mi-temps jusqu’au 31 juillet 1997 ; que celle-ci avait exercé une activité de secrétariat, participé à l’organisation du Festival de Chabichou et reçu des personnes à la permanence de Mme Ségolène ROYAL pour suivre leur dossier, sans préciser quelle était l’importance de ces tâches, et si celle-ci étaient de nature à occuper Mme X... pendant toute la période pour laquelle elle lui allouait une rémunération, la cour d’appel a privé son arrêt de base légale au regard de l’article L. 121-1 du code du travail

3°/ qu’enfin, une association a la qualité d’employeur des personnes qui travaillent pour son compte ; qu’ainsi la cour d’appel en considérant que Mme X... était la salariée de Mme Ségolène ROYAL pour le travail qu’elle aurait effectué pour le compte de l’association du Chabichou présidée par cette dernière, a violé les articles L. 122-1 du code du travail et 6 de la loi du 1er juillet 1901 ;

(le texte qui suit renferme la décision définitive de la Cour de cassation)

Mais attendu, selon l’article L. 122-3-10 devenu L. 1243-11 du code du travail, que dès l’instant que la relation de travail se poursuit à l’expiration du terme du contrat à durée déterminée, le contrat de travail dont les conditions, sauf accord contraire des parties, demeurent inchangées, devient à durée indéterminée ;

Et attendu que la cour d’appel qui, appréciant souverainement les éléments qui lui étaient soumis, a, sans se contredire, constaté que Mme X... avait, dans les conditions du contrat à durée déterminée, poursuivi au delà du 31 mai 1997 son activité de secrétariat dans les locaux de la permanence de Mme Ségolène ROYAL, pour le compte et sous les ordres de cette dernière, a par ces seuls motifs, légalement justifié sa décision ;

PAR CES MOTIFS :
REJETTE le pourvoi ;
Condamne Mme Ségolène ROYAL aux dépens ;
Vu l’article 700 du code de procédure civile, la condamne à payer à Mme X... la somme de 2 500 euros.