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ATA/738/1997•Health coverage abroad and insurer’s information duty
ATA/738/1997Cour de justice / Chambre administrative25 nov. 1997Confirmed
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The dispute concerned whether health insurance had to cover treatment and hospitalization abroad. The court held that the insurer had complied with its duty to inform by publishing the regulatory changes in its journal. It also confirmed a daily benefit of CHF 1,000 for treatment abroad, but reiterated that compulsory health insurance does not cover hospitalization abroad unless it is an emergency. Finally, it stated that Art. 34(2) LAMal does not create a list of foreign services that cannot be provided in Switzerland.
Art. 34 al. 2 LAMal; coverage of treatment abroad and scope of emergency hospitalization abroad; the compulsory health insurance scheme does not cover planned hospitalization abroad, and the statutory provision does not establish a positive catalogue of foreign prestations unavailable in Switzerland. An insurer may satisfy its duty to inform insured persons by publishing regulatory amendments in its official journal, provided the communication is sufficiently accessible. A court may therefore uphold the insurer’s published coverage rules, including a fixed daily benefit for treatment abroad, while denying broader reimbursement for non-emergency hospital care abroad.
Descripteurs
ASSURANCE COMPLEMENTAIRE; AM; SEJOUR A L'HOPITAL; ETAT ETRANGER; ASSURANCE SOCIALE; ASSU
Normes
LAMAL.12 al.2
Résumé
La caisse a respecté son devoir d'information en publiant les modifications réglementaires dans son journal. Le TA a confirmé la couverture de frs 1'000.- par jour prévue pour les traitements à l'étranger. La LAMal ne couvre pas le cas de l'hospitalisation à l'étranger qui n'est pas ordonnée en urgence. Il n'existe pas de liste de prestations fournies à l'étranger qui ne pourraient l'être en Suisse (art. 34 al. 2 LAMal).
Extrait par Omnilex
Whether the insurer satisfied its duty to inform insured persons about regulatory changes by publishing them in its journal.
Yes. The court held that publication in the insurer’s journal was sufficient to satisfy the information duty.
The insurer had duly communicated the regulatory amendments through its journal, so the insured could rely only on the published terms.
Whether the insured was entitled to CHF 1,000 per day for treatment abroad under the applicable coverage rules.
Yes, the cantonal court confirmed the coverage of CHF 1,000 per day for treatment abroad.
The court accepted that this contractual or regulatory daily benefit remained applicable to treatment abroad.
Whether non-emergency hospitalization abroad had to be covered by the compulsory health insurance scheme.
No. The court held that LAMal does not cover hospitalization abroad unless it is ordered as an emergency.
Compulsory health insurance does not extend to planned hospitalization abroad; emergency necessity is required for coverage.
Whether there exists a list of services obtainable abroad that could not be provided in Switzerland under Art. 34(2) LAMal.
No. The court stated that no such list exists.
Art. 34(2) LAMal does not establish a positive catalogue of foreign prestations unavailable in Switzerland.
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