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ATA/214/1997•Non-probative medical evidence leads to remand to CNA
ATA/214/1997Cour de justice / Chambre administrative8 avr. 1997Remanded
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The court held that the medical reports could not be relied upon because the insured had failed to disclose relevant prior medical conditions. As CNA was therefore unable to decide the accident insurance claim on a complete factual basis, the matter was sent back to CNA for renewed examination and decision.
LAA art. 18; probative value of medical assessments in accident insurance proceedings; if relevant prior medical history is not disclosed by the insured and the insurer cannot assess the claim on a complete factual basis, the medical evidence lacks probative force. In such a situation, the decision must be annulled and the matter remitted to the insurer for further clarification and a new decision (consid. unspecified).
Descripteurs
ASSURANCE SOCIALE; ACCIDENT; AA; EXPERTISE; DECISION DE RENVOI; ASSU
Normes
LAA.18
Résumé
Appréciations médicales non probantes en raison d'antécédents médicaux non révélés par l'assuré. La CNA n'ayant pu statuer en pleine connaissance de cause, l'affaire doit lui être renvoyée.
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Whether the medical assessments were probative despite undisclosed prior medical history.
No. The assessments were not sufficiently reliable because relevant antecedents had not been disclosed.
The court found that CNA had not been able to determine the claim with full knowledge of the facts, as the medical basis was incomplete and therefore not decisive.
Whether the matter should be sent back to CNA for a new decision.
Yes. The case had to be remitted to CNA for further clarification and a new assessment.
Because the factual basis was incomplete, the authority could not validly rule on the accident insurance claim and a referral was necessary.
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