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Breast prosthesis and moratory interest in social insurance

ATA/777/1998Cour de justice / Chambre administrative1 déc. 1998Granted

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Extrait par Omnilex

Résumé Omnilex

The insured challenged the insurer's refusal to cover costs linked to breast surgery, including implantation of a breast prosthesis and adaptation of the healthy breast. The court held that the technique used was scientifically recognized and medically appropriate to restore physical integrity, so the prosthesis could not be imposed as an alternative. It further held that adapting the healthy breast was not a purely aesthetic measure but medically justified and involved no additional expense. Owing to the insurer's extreme negligence, the court also ordered exceptional moratory interest at 5%.

Regeste Omnilex

Art. 23 LAMA; breast reconstruction and moratory interest in social insurance. A medically recognized surgical technique that is best suited to restore the insured person's physical integrity is covered; a breast prosthesis cannot be imposed where it is not reasonably preferable. The adaptation of the healthy breast is not purely aesthetic when it is medically dictated by the circumstances, especially if it causes no additional costs. In exceptional cases of particularly negligent conduct by the insurer, the award may include moratory interest at 5% (consid. not stated).

Texte intégral

Descripteurs

ASSURANCE SOCIALE; AM; PROTHESE DU SEIN; CARACTERE SCIENTIFIQUEMENT RECONNU; SOINS DONNES PAR UN MEDECIN; TRAITEMENT(EN GENERAL); PRESTATION D'ASSURANCE(EN GENERAL); ECONOMIE DU TRAITEMENT; SEJOUR A L'HOPITAL; INTERET MORATOIRE; ASSU

Normes

LAMA.23

Résumé

Non seulement la technique utilisée lors de l'opération mammaire subie par la recourante était scientifiquement reconnue, mais elle était encore la mieux adaptée afin de rétablir son intégrité physique. Ainsi, l'implantation d'une prothèse mammaire ne pouvait décemment pas lui être imposée. De même, l'adaptation du sein en bonne santé ne devait pas dans un tel cas être considérée comme étant de nature purement esthétique, mais bien commandée par les circonstances médicales, d'autant que cela n'a pas entraîné de frais supplémentaires. Vu l'extrême légèreté dont a fait preuve l'assurance intimée, elle s'est vue condamnée au versement exceptionnel d'un intérêt moratoire de 5 %.

Mots-clés

social insurancebreast prosthesismedical necessityaesthetic treatmentcoveragemoratory interestsurgical reconstruction

Extrait par Omnilex

Questions juridiques clés extraites par Omnilex

Question juridique clé

Whether implanting a breast prosthesis and adapting the healthy breast were medically necessary and covered under social insurance

Solution extraite

The surgical technique was scientifically recognized and was also the best adapted to restore the appellant's physical integrity; the prosthesis could not reasonably be imposed on her, and the adaptation of the healthy breast was not merely aesthetic but medically required.

Motifs extraits

The court relied on the medical character of the intervention and on the absence of additional costs for the adaptation of the healthy breast, holding that the measures were dictated by the medical circumstances rather than cosmetic considerations.

Question juridique clé

Whether the insurer had to pay an exceptional moratory interest of 5%

Solution extraite

Yes; because of the insurer's extreme negligence, it was ordered to pay moratory interest at 5%.

Motifs extraits

The court considered the insurer's conduct particularly careless, justifying an exceptional interest rate.

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