Accident insurance: no entitlement to balneary cure at Abano

ATA/756/1997Cour de justice / Chambre administrative9 déc. 1997Dismissed

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Résumé Omnilex

The court dismissed the insured person's appeal against the accident insurer's refusal to finance a balneary cure in Abano. Although the medical expert referred to a possible beneficial effect, this was limited to a certain sense of well-being for a few months and did not amount to a notable reduction of pain. The court held that the requirements for treatment coverage under Art. 21(1) LAA were therefore not met.

Regeste Omnilex

Art. 21 al. 1 LAA; entitlement to medical treatment measures after accident and balneary cure. Coverage requires that the measure be shown, on the basis of the medical evidence, to be apt to produce a relevant therapeutic improvement. A merely palliative or comfort-enhancing effect, such as a certain well-being for a limited period, does not suffice. Where the expert cannot attest to a substantial diminution of pain or comparable medical benefit, the insurer may refuse assumption of the costs.

Texte intégral

Descripteurs

ASSURANCE SOCIALE; ACCIDENT; AA; SYNDROME CERVICAL; LESION DE LA COLONNE VERTEBRALE; CURE DE CONVALESCENCE; DIAGNOSTIC; EXPERTISE; SOINS MEDICAUX; FRAIS(EN GENERAL); PRESTATION D'ASSURANCE(EN GENERAL); TRAUMATISME CERVICAL; CURE BALNEAIRE; LIMITATION; ASSU

Normes

LAA.21 al.1

Résumé

Rejet d'un recours contre le refus de prendre une cure balnéaire à Abano, dans la mesure où l'expert n'a pas pu qualifier les améliorations potentiellement attendues de diminution notable des douleurs ressenties, mais simplement d'apport d'"un certain bien-être pour une période de quelques mois".

Mots-clés

social insuranceaccident insurancebalneary curemedical expensesexpert opinioncervical syndromepain reduction

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Questions juridiques clés extraites par Omnilex

Question juridique clé

Whether accident insurance had to cover a balneary cure at Abano as medically necessary treatment

Solution extraite

The cure was not shown to be a treatment measure whose expected benefit amounted to a notable reduction of pain; the anticipated effect was only some temporary well-being for a few months.

Motifs extraits

Under Art. 21 para. 1 UVG/LAA, the insured must establish that the measure is a required medical treatment or equivalent benefit. The expert evidence did not support such a level of therapeutic necessity.

Accident insurance: no entitlement to balneary cure at AbanoGénéré par IA