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No reduction of accident coverage for non-seatbelt use

ATA/812/1998Corte di giustizia / Camera amministrativa15 dic 1998Granted

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Estratto da Omnilex

Sintesi Omnilex

The court held that a health insurer covering accident risk under the subsidiary rule of Art. 1(2)(b) KVG/LAMal cannot reduce benefits for treatment and expense reimbursement merely because the insured failed to wear a seatbelt or accepted a ride with an intoxicated driver. A reduction is permissible only where the insured intentionally caused the injury within the meaning of Art. 37 LAA. Gross negligence alone is insufficient.

Massima Omnilex

Art. 1 al. 2 let. b LAMal; accident coverage by the health insurer and benefit reduction: the health insurer, when assuming accident risk under the statutory subsidiary rule, may reduce benefits for treatment and reimbursement of expenses only in the case of intentional self-inflicted injury within the meaning of Art. 37 LAA. Gross negligence, in particular failure to wear a seatbelt or riding with an intoxicated driver, does not justify reduction (consid. ?).

Testo completo

Descripteurs

ASSURANCE SOCIALE; AM; ACCIDENT; AA; CLAUSE DE SUBSIDIARITE; FAUTE; REDUCTION DE LA PRESTATION D'ASSURANCE; PRESTATION D'ASSURANCE(EN GENERAL); ASSU

Normes

LAMAL.1 al.2 litt.b

Résumé

Une caisse-maladie doit prendre en charge les frais liés à un accident même lorsque l'assuré a conclu une assurance accident pour occupant privée qui ne verse pas de prestation en raison d'une faute grave. Le fait de ne pas avoir attaché sa ceinture ne peut être invoqué valablement pour réduire les prestations pour soins et remboursement de frais sur la base de l'art. 37 al. 1 LAA. L'assureur-maladie qui doit couvrir le risque accident dans le cadre de l'article 1 alinéa 2 lettre b LAMal, ne peut réduire ses prestations pour soins et remboursement de frais qu'en cas d'atteinte à la santé provoquée intentionnellement par l'assuré (art. 37 LAA). Tel n'est pas le cas de l'assuré qui a un accident de voiture alors qu'il n'avait pas sa ceinture de sécurité et qu'il avait pris place à côté d'un conducteur en état d'ébriété.

Parole chiave

social insuranceaccident coveragesubsidiaritygross negligenceseatbeltbenefit reductionhealth insurer

Estratto da Omnilex

Questioni giuridiche chiave estratte da Omnilex

Questione giuridica chiave

Whether the health insurer covering accident risk under Art. 1(2)(b) KVG/LAMal may reduce treatment and expense benefits because the insured did not wear a seatbelt and rode with an intoxicated driver.

Decisione estratta

No. The insurer may reduce such benefits only if the insured intentionally caused the health impairment; mere gross negligence is insufficient.

Motivazione estratta

The accident coverage assumed by the health insurer under the statutory subsidiary clause is limited by the reduction rule of Art. 37 LAA only for intentional self-inflicted injury. Failure to wear a seatbelt does not satisfy that threshold.

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