Daily allowance: partial incapacity after depression

ATA/424/1998Cour de justice / Chambre administrative28 juil. 1998Partially Granted

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Résumé Omnilex

The case concerned social insurance daily allowances following a major depressive episode, with additional hearing problems mentioned. The court accepted the medical expert’s conclusions and recognized a total incapacity for work for about 4.5 months, followed by a 50% incapacity for slightly more than 11 months. The dispute was therefore only partially successful for the insured, with entitlement limited to the medically established periods and degree of incapacity.

Regeste Omnilex

LAMA art. 12bis; entitlement to daily allowances depends on medically established incapacity for work. Where an expert opinion is convincing and consistent, the court may rely on it to fix both the degree and duration of incapacity. A major depressive episode can justify full incapacity for work for the acute phase, followed by a reduced incapacity once the condition improves; the assessment must be individualized and based on the concrete medical evidence.

Texte intégral

Descripteurs

ASSURANCE SOCIALE; AM; INCAPACITE DE TRAVAIL; DEPRESSION; DIAGNOSTIC; TROUBLE AUDITIF; INVALIDITE(INFIRMITE); EXPERTISE; CAPACITE DE TRAVAIL PARTIELLE; CONDITIONS GENERALES DU CONTRAT; PSYCHOTHERAPIE; INDEMNITE JOURNALIERE; LIMITATION; DOMMAGE; OBLIGATION DE REDUIRE LE DOMMAGE; AFFECTION PSYCHIQUE; ASSU

Normes

LAMA.12bis

Résumé

Reconnaissance d'une incapacité totale de travail pour dépression majeure durant 4 mois 1/2, puis limitée à 50 % durant un peu plus de 11 mois, conformément aux conclusions de l'expert.

Mots-clés

social insurancedaily allowanceincapacity for workdepressionexpert opinionpartial incapacitypsychological disorderobligation to mitigate damage

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Questions juridiques clés extraites par Omnilex

Question juridique clé

Extent and duration of incapacity for work due to depression and hearing impairment under the insurance contract

Solution extraite

The insured had a total incapacity for work for 4.5 months because of major depression, then a 50% incapacity for a little more than 11 months, in line with the expert opinion.

Motifs extraits

The court relied on the expert assessment and accepted that the psychiatric condition justified a full incapacity initially, followed by a medically established partial incapacity.

Daily allowance: partial incapacity after depressionGénéré par IA