Mandatory coverage of hospital rehabilitation after acute illness

ATA/126/1997Tribunal de Justiça / Câmara Administrativa18 de fev. de 1997Granted

Extraído pela Omnilex

Resumo Omnilex

The insured was hospitalized following an infarction and then underwent a rehabilitation stay of more than four months at Beau-Séjour. The court held that because the rehabilitation treatment followed immediately after hospitalization for an acute illness, it had to be borne by the compulsory health insurance under LAMA art. 12 para. 2. The insurer was therefore ordered to assume the costs of the stay.

Sumário Omnilex

LAMA art. 12 para. 2; hospital rehabilitation immediately following treatment for an acute illness is compulsory coverage. A rehabilitation stay that is the direct and immediate continuation of acute hospital treatment falls within the mandatory benefits of health insurance and must be borne by the caisse-maladie; the decisive factor is the close temporal and medical connection with the acute episode, not the duration of the rehabilitation stay.

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; SEJOUR A L'HOPITAL; MESURE MEDICALE DE READAPTATION; INFARCTUS; PRESTATION OBLIGATOIRE; ASSU

Normes

LAMA.12 al.2

Résumé

- Un traitement hospitalier de rééducation qui suit immédiatement une hospitalisation pour maladie aiguë est obligatoirement à la charge des caisses-maladie (application de la LAMA).

- La caisse-maladie a été condamnée à prendre en charge une hospitalisation de plus de 4 mois à Beau-Séjour, lequel faisait suite à un infarctus.

Palavras-chave

social insurancehealth insurancehospital rehabilitationacute illnessmyocardial infarctionmandatory coverage

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether hospital rehabilitation immediately following hospitalization for an acute illness must be covered by the health insurer under LAMA art. 12 para. 2.

Decisão extraída

Yes. A hospital rehabilitation treatment that follows immediately after hospitalization for an acute illness is mandatorily covered by the health insurer.

Fundamentação extraída

The court treated the rehabilitation stay as a continuation of the acute treatment, so it fell within the compulsory benefits regime of the LAMA.

Mandatory coverage of hospital rehabilitation after acute illnessGerado por IA