ATA/179/1998•Traumatic elbow lesion covered, epicondylitis excluded
ATA/179/1998Tribunal de Justiça / Câmara Administrativa31 de mar. de 1998Partially Granted
Extraído pela Omnilex
Mobile ossified fragments found at the elbow were accepted as a traumatic lesion and therefore accident-related. By contrast, epicondylitis was not considered causally related to the accident. The practical consequence was that the accident insurer had to bear only 70% of the elbow operation, with the remainder excluded from coverage.
Art. 6 LAA; natural causality in accident insurance for combined elbow pathologies; fragments ossifiés mobiles at the elbow may be treated as a traumatic lesion if the medical findings support an accident-related origin, whereas epicondylitis is not presumed traumatic merely because it coexists with such lesions. Coverage is therefore limited to the portion of treatment causally linked to the accident; non-traumatic concomitant pathology falls outside the insurer's duty to provide benefits.
Descripteurs
ASSURANCE SOCIALE; ACCIDENT; AA; LESION TRAUMATIQUE; EPICONDYLITE; CAUSALITE NATURELLE; ASSU
Normes
LAA.6
Résumé
Dès lors que des fragments ossifiés mobiles ont été constatés au niveau du coude, il sera admis que cette lésion est d'origine traumatique. Il n'en est pas de même de l'épicondylite. C'est pourquoi l'assureur-accident ne prendra en charge que 70 % de l'opération du coude.
Extraído pela Omnilex
Whether the elbow lesion with mobile ossified fragments was naturally causally related to an accident.
Yes. The presence of mobile ossified fragments at the elbow justified treating that lesion as traumatic in origin.
The court accepted the traumatic origin of the lesion because the medical findings showed mobile ossified fragments at the elbow.
Whether the epicondylitis was naturally causally related to the accident and thus had to be covered by accident insurance.
No. The epicondylitis was not regarded as accident-related.
Unlike the ossified fragments, the epicondylitis was not admitted as traumatic in origin, so it fell outside accident coverage.
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