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ATA/766/1998•Daily allowances and duty to mitigate under LAMal
ATA/766/1998Cour de justice / Chambre administrative1 déc. 1998Confirmed
Extrait par Omnilex
The insured, suffering from arthrosis, challenged the insurer's limitation of daily allowances and claimed an automatic entitlement to 720 days of benefits within a 900-day period. The court held that granting him 5.5 months to find adapted work fully complied with the relevant case law. Because the insured must mitigate the loss, he could not rely on an automatic maximum entitlement, nor could he derive such a right from equal-treatment principles. The challenged decision was therefore confirmed.
Art. 72 al. 2 LAMal; daily allowances and duty to mitigate damage: the insured person must make all reasonable efforts to reduce the loss, including seeking adapted work. The insurer may set a reasonable period for reintegration; a period of 5.5 months was held sufficient in view of the insured's arthrosis (consid. unspecified). The insured cannot invoke equality of treatment to claim an unconditional right to 720 daily allowances within 900 days where the duty to mitigate has not been met. The entitlement to benefits is therefore limited by the obligation to reduce damage and by the factual availability of adapted employment.
Descripteurs
ASSURANCE SOCIALE; AM; INDEMNITE JOURNALIERE; INCAPACITE DE TRAVAIL; DOMMAGE; LIMITATION; OBLIGATION DE REDUIRE LE DOMMAGE; PHYSIOTHERAPIE; ARTHROSE; EGALITE DE TRAITEMENT; ASSU
Normes
LAMAL.72 al.2
Résumé
En laissant au recourant un délai de 5 mois et demi pour trouver une nouvelle activité adaptée à ses problèmes d'arthrose, l'intimée s'est conformée en tous points à la jurisprudence et sa décision ne peut qu'être confirmée. L'assuré étant tenu de tout mettre en oeuvre pour réduire le dommage, il ne peut revendiquer le droit automatique au versement d'indemnités journalières durant 720 jours dans le délai de 900 jours, même par application du principe de l'égalité de traitement.
Extrait par Omnilex
Whether the insurer allowed sufficient time for the insured to find adapted work despite arthrosis
A period of 5.5 months to seek a new adapted activity was sufficient and complied with the case law.
The insurer's approach was consistent with the duty to mitigate damage; the insured could not demand unrestricted continued benefits during that period.
Whether the insured had an automatic right to 720 daily allowance days within 900 days under Article 72 paragraph 2 LAMal, including on equal-treatment grounds
No automatic entitlement existed in these circumstances.
The insured must take all reasonable steps to reduce the loss; equality of treatment does not override that duty or create an unconditional claim to the full daily-allowance period.
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