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Insurer may not demand power of attorney to consult prior medical file

ATA/107/1998Cour de justice / Chambre administrative4 mars 1998Granted

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Extrait par Omnilex

Résumé Omnilex

The dispute concerned whether the health insurer, when determining coverage of medical expenses under compulsory health insurance, could require the insured to sign a power of attorney allowing direct consultation of the file held by the former insurer. The court held that the insurer must base its decision on the information provided by its medical adviser and cannot insist on such an additional authorization. The insured therefore prevailed on this point.

Regeste Omnilex

Art. 57 al. 4 LAMal; determining coverage of medical expenses under compulsory health insurance; the insurer may rely on the indications furnished by its medical adviser and is not entitled, as a condition for deciding on coverage, to require the insured to grant a power of attorney enabling direct consultation of the medical file held by a former insurer. The provision governs the insurer’s internal assessment of the necessity and scope of treatment costs; it does not create a right to compel direct file access through the insured beyond the adviser-based assessment mechanism.

Texte intégral

Descripteurs

ASSURANCE SOCIALE; AM; ASSURANCE OBLIGATOIRE; ASSUREUR; CONTROLE MEDICAL; FRAIS(EN GENERAL); REMBOURSEMENT DE FRAIS(ASSURANCE); ASSUREUR-MALADIE; ECONOMIE DU TRAITEMENT; PROCURATION; CONSULTATION DU DOSSIER; ASSU

Normes

LAMAL.57 al.4

Résumé

La caisse-maladie du recourant doit se déterminer, quant à la prise en charge de ses frais médicaux relevant de l'assurance obligatoire, en fonction des seules indications que lui a fournies son médecin-conseil. Elle n'a pas à requérir, en sus, une procuration lui permettant de consulter le dossier médical auprès de l'ancien assureur. La caisse-maladie doit déterminer la prise en charge des frais médicaux en fonction des seules indications que lui a fournies son médecin-conseil. Elle ne peut requérir, en sus, une procuration lui permettant de consulter directement le dossier médical de l'assuré auprès de l'ancien assureur.

Mots-clés

social insurancecompulsory health insurancemedical advisermedical file accesspower of attorneyreimbursement of costsformer insurertreatment economy

Extrait par Omnilex

Questions juridiques clés extraites par Omnilex

Question juridique clé

Whether the health insurer may require a power of attorney to consult the insured’s medical file from the former insurer before deciding coverage of compulsory insurance medical costs.

Solution extraite

No. The insurer must decide on coverage based only on the information provided by its medical adviser and may not require an additional power of attorney for direct access to the insured’s file held by the former insurer.

Motifs extraits

The court held that the insurer’s decision-making under compulsory health insurance is based on the indications furnished by its medical adviser; a separate authorization to obtain the medical file from the former insurer is not required.

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