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ATA/54/1997•Dental costs from autoimmune disease not covered by compulsory insurance
ATA/54/1997Court of Justice / Administrative ChamberJan 21, 1997Dismissed
Extracted by Omnilex
The dispute concerned whether dental expenses caused by an autoimmune disease had to be reimbursed by compulsory health insurers. The court held that, under the applicable health insurance statute, such dental costs are not covered merely because the underlying condition is autoimmune. The claim for reimbursement was therefore rejected.
LAMA art. 12; compulsory health insurance coverage for dental treatment costs caused by an autoimmune disease. Dental treatment expenses are not covered merely because they stem from an autoimmune disorder; coverage requires a statutory basis extending the benefit to such treatment, which is absent here.
Descripteurs
ASSURANCE SOCIALE; AM; AFFECTION DENTAIRE; PRINCIPE DE LA BONNE FOI; TRAITEMENT DENTAIRE; ASSU
Normes
LAMA.12
Résumé
En application de la LAMA, les frais dentaires engendrés par une maladie auto-immune ne doivent pas êtrte pris en charge par les caisses-maladie.
Extracted by Omnilex
Whether dental treatment costs caused by an autoimmune disease are covered by compulsory health insurance.
Such dental costs are not to be borne by the health insurer under the applicable compulsory health insurance rules.
The court held that the causal link to an autoimmune disease does not, by itself, make the dental treatment a covered benefit under the compulsory insurance scheme.
Whether the insured person could rely on good faith to obtain coverage.
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