Sickness insurer may consider later AI findings on work capacity

ATA/741/1998Court of Justice / Administrative ChamberNov 24, 1998Not Examined

Extracted by Omnilex

Omnilex summary

The decision concerns coordination between sickness insurance and invalidity insurance in relation to daily allowances. Because the sickness insurer and the AI reached different conclusions on the insured person's residual work capacity, the court held that the AI's later findings could be considered despite having been issued after the contested decision. This discrepancy justified departing from the insurer's assessment.

Omnilex headnote

Art. 72 al. 2 LAMal; coordination between sickness insurance and invalidity insurance in the assessment of residual work capacity; where the evaluations of the sickness insurer and the AI diverge, later AI conclusions may be taken into account if they are necessary to determine the insured person's effective work capacity. The decisive point is not the formal date of the AI decision, but its probative value for clarifying the medical and occupational situation (consid. null).

Full text

Descripteurs

ASSURANCE SOCIALE; AM; AI(ASSURANCE); INDEMNITE JOURNALIERE; COLLABORATION ENTRE AUTORITES; ORGANISATION(PROCEDURE); COORDINATION(ASSURANCE); PROCEDURE; ASSU

Normes

LAMAL.72 al.2

Résumé

Ecart entre l'évaluation de la caisse-maladie et celle de l'AI à propos de la capacité résiduelle de travail de l'assuré, tel qu'il justifie une prise en compte des conclusions de l'AI postérieures à la décision litigieuse.

Keywords

social insuranceinvalidity insurancedaily allowancescoordination between authoritiesprocedureresidual work capacityevidence assessment

Extracted by Omnilex

Key legal questions extracted by Omnilex

Key legal question

Whether a discrepancy between the sickness insurer's and the AI's assessment of residual work capacity justifies taking account of AI findings issued after the contested decision.

Extracted holding

Yes. Where the assessments diverge, later AI conclusions may be taken into account for determining the insured person's residual work capacity.

Extracted reasoning

The divergence between the two assessments justified relying on the later AI conclusions, even though they postdated the contested decision, because they were relevant to clarifying the insured person's actual work capacity.

Sickness insurer may consider later AI findings on work capacityAI generated