Health insurer must advance benefits pending causation finding

ATA/72/1998Court of Justice / Administrative ChamberFeb 10, 1998Granted

Extracted by Omnilex

Omnilex summary

The court held that where it is not yet settled whether medical expenses are causally connected to an accident, the health insurer must advance the insured benefits. The unresolved causation issue does not allow the insurer to withhold payment pending clarification.

Omnilex headnote

OAMal 112 al. 1; lorsque le lien de causalité entre les frais médicaux et l’accident n’est pas encore tranché, l’assureur-maladie est tenu d’avancer les prestations assurées. Le mécanisme d’avance s’impose tant que l’imputabilité des frais à l’accident demeure incertaine, afin d’éviter une lacune de couverture; la clarification ultérieure de la causalité détermine ensuite la charge définitive de l’assurance tenue de prester.

Full text

Descripteurs

ASSURANCE SOCIALE; ACCIDENT; AA; PRESTATION D'ASSURANCE(AA); AVANCE(EN GENERAL); ASSU

Normes

OAMAL.112 al.1

Résumé

Dès lors que la question du lien de causalité entre les frais médicaux et l'accident n'est pas résolue, il incombe à l'assureur-maladie d'avancer les prestations assurées par lui.

Keywords

social insuranceaccident insurancehealth insuranceadvance paymentcausationmedical expenses

Extracted by Omnilex

Key legal questions extracted by Omnilex

Key legal question

Whether the health insurer must advance insured benefits while causation between the medical expenses and the accident remains unresolved.

Extracted holding

Yes. Until the causal link is determined, the health insurer must advance the benefits covered by it.

Extracted reasoning

Because the question whether the medical expenses are causally linked to the accident has not yet been resolved, the advance-payment mechanism applies to avoid a gap in coverage.

Health insurer must advance benefits pending causation findingAI generated