Conflict between insurer and disability assessment

ATA/300/1997Cour de justice / Chambre administrative15 mai 1997Remanded

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Résumé Omnilex

The case concerned social insurance daily benefits. The caisse concluded that the insured person had full work capacity, whereas the disability insurance authority found 85% disability. The court held that such a major discrepancy could not be ignored. It annulled the caisse’s decision and remanded the file for further examination.

Regeste Omnilex

LAMA 12 bis al. 1; where the competent insurer’s assessment of work capacity is in marked contradiction with the disability insurance authority’s assessment, the divergence cannot be disregarded. Such a substantial inconsistency requires annulment of the insurer’s decision and remand for renewed assessment; the authority must resolve the evidentiary conflict before deciding on entitlement to daily benefits.

Texte intégral

Descripteurs

ASSURANCE SOCIALE; AM; INDEMNITE JOURNALIERE; ASSU

Normes

LAMA.12 bis al.1

Résumé

Il y a en l'espèce un tel écart entre la décision de la caisse, qui conclut à la pleine capacité de travail de l'assuré, et celle de l'AI, qui conclut à une invalidité de 85 %, que l'on n'en saurait faire abstraction. La décision de la caisse doit être annulée et le dossier doit lui être renvoyé.

Mots-clés

social insurancedaily allowancework capacitydisability assessmentremand

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Questions juridiques clés extraites par Omnilex

Question juridique clé

Whether the caisse’s decision on work capacity could stand despite a major divergence from the disability insurance assessment.

Solution extraite

No. The discrepancy was so significant that it could not be disregarded; the caisse’s decision had to be annulled and the case remanded.

Motifs extraits

The court held that a finding of full work capacity by the caisse was incompatible with the disability insurance assessment of 85% disability, and this conflict required further examination by the caisse.

Conflict between insurer and disability assessmentGénéré par IA