ATA/103/1998•Tooth fracture from biting into bone as an accident
ATA/103/1998Tribunal de Justiça / Câmara Administrativa4 de mar. de 1998Granted
Extraído pela Omnilex
The dispute concerned whether a tooth fracture caused by biting into a piece of bone contained in a sausage was covered as an accident under compulsory health insurance. The court held that the presence of the bone was extraordinary and that the insured event therefore qualified as an accident, notwithstanding any dental predisposition. Coverage and reimbursement were accordingly admitted.
Art. 2 al. 2 LAMal; accident character of a tooth fracture caused by biting into a foreign object in food. An accident is present where an external factor has an extraordinary character. The fact that the insured person bites into an unusual piece of bone contained in a sausage and thereby fractures a tooth constitutes such an extraordinary external event. A predisposition of the teeth does not exclude accident status where the triggering event itself is extraordinary.
Descripteurs
ASSURANCE SOCIALE; ACCIDENT; AA; AFFECTION DENTAIRE; FRACTURE; PREDISPOSITION; COUVERTURE; FRAIS(EN GENERAL); REMBOURSEMENT DE FRAIS(ASSURANCE); ASSU
Normes
LAMAL.2 al.2
Résumé
La présence d'un morceau d'os dans un saucisson a un caractère extraordinaire : Est un accident le fait de se briser une dent en mordant dans ledit os.
Extraído pela Omnilex
Whether breaking a tooth by biting into a bone in a sausage qualifies as an accident under social insurance law.
Yes. The event had an extraordinary character and constituted an accident.
A piece of bone in a sausage is an unusual external factor. Biting into it and fracturing a tooth therefore meets the accident requirement despite any dental predisposition.
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