Le salarié qui voit son état de santé se dégrader et qui estime que cette dégradation est liée à ses conditions de travail peut demander à la caisse primaire d’assurance maladie (CPAM) que soit reconnu le caractère professionnel de sa maladie. Et la procédure qui s’impose à la caisse pour statuer sur cette demande vient d’être remaniée…
Précision : cette nouvelle procédure s’applique aux demandes de reconnaissance de maladies professionnelles effectuées à partir du 1er décembre 2019.
La CPAM statue seule…
La procédure de reconnaissance d’une maladie professionnelle débute lorsque la CPAM dispose de la demande du salarié, du certificat initial établi par son médecin ainsi que, le cas échéant, des examens médicaux supplémentaires qui ont été réalisés. L’employeur et le salarié sont alors destinataires d’un questionnaire qu’ils doivent retourner dans les 30 jours. En pratique, la CPAM adresse un courrier recommandé aux parties les informant qu’un questionnaire est mis à leur disposition sur le site https://questionnaires-risquepro.ameli.fr.
Précision : la CPAM peut mener une enquête complémentaire et, par exemple, interroger tout médecin du travail et tout employeur du salarié.
Au terme de ses investigations et au plus tard 100 jours après le début de la procédure, la CPAM doit mettre le dossier contradictoire à la disposition de l’employeur et du salarié. Ces derniers pouvant formuler leurs observations pendant un délai de 10 jours.
À noter : la caisse informe, par tout moyen conférant date certaine, l’employeur et le salarié de la période au cours de laquelle ils peuvent consulter le dossier ainsi que du délai qui leur est accordé pour formuler leurs observations. Et ce, au moins 10 jours avant la mise à disposition du dossier contradictoire.
En tout et pour tout, la caisse dispose de 120 jours, à compter du début de la procédure, pour statuer sur le caractère professionnel ou non de la maladie. Sauf si, avant la fin de ce délai, elle saisit le comité régional de reconnaissance des maladies professionnelles (CRRMP).
… ou avec l’appui du CRRMP
Le CRRMP est saisi dès lors que la maladie dont souffre le salarié peut être rattachée à l’une des maladies professionnelles reconnues par la Sécurité sociale (tableaux), mais que l’une des conditions administratives requises n’est pas remplie (durée d’exposition à un risque professionnel, travaux concernés par la maladie…). Ou bien lorsque la maladie du salarié ne figure pas dans les tableaux de maladies professionnelles de la Sécurité sociale et que le salarié est décédé ou que son taux d’incapacité est d’au moins 25 %.
Et si la CPAM saisit le CRRMP, un nouveau délai de 120 jours lui est accordé pour rendre sa décision. Le dossier contradictoire est alors mis à la disposition de l’employeur et du salarié pendant 40 jours. Un délai durant lequel ils peuvent consulter le dossier et formuler leurs observations. Ils ont même la possibilité de compléter le dossier, mais pendant les 30 premiers jours seulement.
Précision : la CPAM informe l’employeur et le salarié de ces différentes phases, par tout moyen conférant date certaine, lorsqu’elle saisit le CRRMP.
Une fois saisi, le CRRMP dispose de 110 jours pour faire connaître sa décision à la CPAM, laquelle n’a plus que 10 jours pour notifier cette décision à l’employeur et au salarié…
En complément : en cas de rechute ou de nouvelles lésions du salarié, la CPAM a 60 jours pour se prononcer sur son lien avec la maladie professionnelle concernée. L’employeur, auquel la caisse doit adresser un double du certificat constatant la rechute ou les nouvelles lésions, peut formuler des réserves pendant une période de 10 jours.
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