Psychotherapy reimbursement beyond OPAS limits denied

ATA/212/1998Tribunal de Justiça / Câmara Administrativa21 de abr. de 1998Dismissed

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Extraído pela Omnilex

Resumo Omnilex

The appellant requested compulsory health insurance coverage for psychotherapy exceeding the standard limits. The court found that he failed to prove that his case justified treatment beyond two one-hour sessions weekly during the first three years and one one-hour session weekly during the next three years. The appeal was dismissed and the reimbursement request rejected.

Sumário Omnilex

Art. 32 LAMal; Art. 3 OPAS; compulsory health insurance coverage for psychotherapy beyond the regulatory treatment limits requires proof of medical necessity for an exceptional extension. The insured person bears the burden of showing that the case departs from the ordinary therapeutic framework; absent such proof, reimbursement above the prescribed session frequency must be refused (consid. n/a).

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; ECONOMIE DU TRAITEMENT; DEPRESSION; MALADIE DE LONGUE DUREE; PSYCHOTHERAPIE; THERAPIE; TRAITEMENT(EN GENERAL); PRESTATION D'ASSURANCE(EN GENERAL); REMBOURSEMENT DE FRAIS(ASSURANCE); ASSU

Normes

LAMAL.32

Résumé

Le recourant n'a pas démontré que son cas justifiait une prise en charge psycho-thérapeutique excédant les deux séances d'une heure par semaine pendant les trois premières années, puis une séance d'une heure par semaine pendant les trois années suivantes, conformément à ce que prévoit l'art. 3 OPAS.

Palavras-chave

social insurancehealth insurancepsychotherapymedical necessityreimbursementtreatment limitsdepressionlong-term illness

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether compulsory health insurance had to cover psychotherapy beyond the limits set by Art. 3 OPAS.

Decisão extraída

No. The appellant did not demonstrate that his condition justified psychotherapy exceeding two one-hour sessions per week for the first three years and one one-hour session per week for the following three years.

Fundamentação extraída

The evidence did not establish a medically necessary exception to the standard coverage limits for psychotherapy under the implementing ordinance.

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