No entitlement to fixed premiums for three years

ATA/778/1998Cour de justice / Chambre administrative1 déc. 1998Dismissed

Extrait par Omnilex

Résumé Omnilex

The insured claimed that his health insurance premiums were fixed for three years under the policy and invoked good faith. The court held that the policy only set the duration of the contract, not the premium amount. Premiums were governed by the premium statement, which expressly reserved the insurer's right to increase them and the insured's right to switch insurers. Since no document stated that premiums were blocked for three years, the appeal failed.

Regeste Omnilex

Art. 7 al. 2 LAMal; interpretation of insurance documents and reliance on good faith: a policy clause fixing the duration of the insurance contract does not, by itself, establish a three-year freeze on premiums. Where the premium is regulated separately in the premium statement and that statement expressly reserves the insurer's right to adjust premiums while safeguarding the insured's option to change insurers, the insured cannot infer a contractual limitation on premium increases from silence in the policy or from other documents. The decisive element is the consistent documentary content; absent an express premium guarantee, no binding promise to maintain the premium level exists.

Texte intégral

Descripteurs

ASSURANCE SOCIALE; AM; ASSUREUR; COUVERTURE; PRIME D'ASSURANCE; PROCEDURE; PRINCIPE DE LA BONNE FOI; INTERPRETATION(SENS GENERAL); ASSU

Normes

LAMAL.7 al.2

Résumé

La police d'assurance du recourant contient une clause précisant que sa durée est fixée à 3 ans. Elle ne fixe cependant à nulle part le montant des primes. Ce point est réglé exclusivement par le décompte des primes, lequel réserve expressément le droit de l'assureur de les augmenter et corrélativement celui de l'assuré de changer d'assureur dans une telle hypothèse. Par ailleurs, aucun des documents remis par la caisse au recourant ne contient la précision que les primes seraient bloquées pour une durée de 3 ans, de sorte que celui-ci ne peut s'en prévaloir.

Mots-clés

social insurancehealth insurancepremiumcontract interpretationgood faithcoverageinsurance policy

Extrait par Omnilex

Questions juridiques clés extraites par Omnilex

Question juridique clé

Whether the insurance policy and related documents bound the insurer to keep premiums unchanged for three years under good faith and Art. 7(2) LAMal.

Solution extraite

No. The policy fixed the contract term at three years, but it did not fix the premium amount. The premium statement governed premiums and expressly reserved the insurer's right to increase them, with a corresponding right for the insured to change insurers.

Motifs extraits

The court relied on the wording of the policy and the premium settlement. Because no document stated that premiums were frozen for three years, the insured could not invoke such a limitation.

No entitlement to fixed premiums for three yearsGénéré par IA