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Hospital treatment: determining predominant purpose under compulsory insurance

ATA/440/1996Cour de justice / Chambre administrative27 août 1996Dismissed

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Résumé Omnilex

The court held that where hospital measures could fall partly under compulsory benefits and partly under supplementary benefits not held by the insured, the decisive criterion is the predominant purpose of the hospitalization. In the present case, the insured suffered from depression, but there was no basis to find that its treatment could not be separated from treatment of the consequences of an assault abroad or that the latter treatment was predominant. The claim for coverage under compulsory insurance was therefore rejected.

Regeste Omnilex

Art. 12 LAMA; hospital stay involving concurrent medical measures potentially falling under compulsory and supplementary insurance: in such mixed cases, coverage under compulsory insurance depends on the predominant purpose of the hospitalization. If the disease-related treatment can be separated from the accident-related treatment and the latter is not shown to be predominant, the stay is not to be classified by reference to the accident consequences alone (consid. 1).

Texte intégral

Descripteurs

ASSURANCE SOCIALE; ACCIDENT; AA; AM; SEJOUR A L'HOPITAL; ASSU

Normes

LAMA.12

Résumé

Lorsque des mesures prises au cours d'une hospitalisation ressortent d'une part du domaine des prestations obligatoires et d'autre part de prestations dues au titre d'une assurance complémentaire dont l'assuré ne bénéficie pas, il y a lieu de déterminer le but prépondérant de l'hospitalisation litigieuse (ATF 120 V 214). En l'espèce, l'assuré souffrait de dépression mais rien ne permettait de considérer que le traitement de cette dernière affection, à caractère de maladie, ne pouvait être entreprise séparément de celui des suites d'une agression, à caractère d'accident, subie à l'étranger, et que les mesures thérapeutiques s'y rapportant revêtaient un caractère prépondérant.

Mots-clés

social insuranceaccidenthospitalizationsupplementary insurancecompulsory benefitspredominant purposecoverage

Extrait par Omnilex

Questions juridiques clés extraites par Omnilex

Question juridique clé

Whether hospital treatment that overlaps compulsory and supplementary benefits is covered under compulsory insurance when the insured lacks supplementary coverage.

Solution extraite

Coverage depends on the predominant purpose of the hospitalization; the stay was not shown to have a predominant accident-related therapeutic purpose separable from treatment of depression as a disease.

Motifs extraits

When measures during hospitalization fall partly within mandatory benefits and partly within supplementary benefits not held by the insured, the decisive criterion is the predominant purpose of the disputed hospitalization. Here, nothing showed that treatment of the depressive disorder could not be undertaken separately from treatment of the accident consequences and that the therapeutic measures related to the accident were predominant.

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