ATA/236/1998•No reticence for undisclosed congenital mole
ATA/236/1998Tribunal de Justiça / Câmara Administrativa28 de abr. de 1998Partially Granted
Extraído pela Omnilex
The insured failed to mention a congenital mole when switching to a new supplementary insurer. After the mole degenerated and had to be removed, the court held that her omission did not constitute reticence because she had never been warned by her doctor about any health risk. The insurer was nevertheless not liable for the full intervention: because it had restricted coverage for plastic and reconstructive surgery, only 50% of the procedure, corresponding to the reconstructive graft, had to be covered.
Art. 6 LCA; reticence and scope of disclosure duty in supplementary health insurance. An omission is not a reticence where the insured was not informed by the treating physician that an existing bodily feature or condition entailed a health risk. The assessment depends on whether the omitted fact, in light of the insured's knowledge and warnings received, could objectively be regarded as a relevant risk circumstance. Where an insurer limits coverage to plastic and reconstructive surgery, reimbursement may be confined to the portion of the intervention qualifying as such, even if the underlying ablation is medically indicated.
Descripteurs
ASSURANCE SOCIALE; LOI SUR LE CONTRAT D'ASSURANCE; VIOLATION DE L'OBLIGATION D'ANNONCER; OPERATION PLASTIQUE; ASSURANCE COMPLEMENTAIRE; ASSU
Normes
LCA.6
Résumé
L'on ne peut admettre une réticence dans le cas de l'assurée qui ne signale pas à sa nouvelle assurance l'existence d'un grain de beauté congénital sur son nez, lequel dégénère après l'affiliation et doit faire l'objet d'une ablation. Seuls 50 % de frais sont à la charge de l'assurance dès lors que celle-ci restreint ses prétentions en cas de chirurgie plastique et reconstructive et que 50 % de l'intervention constitue une telle chirurgie (greffe à la suite de l'ablation). L'assurée qui ne signale pas à sa nouvelle assurance l'existence d'un grain de beauté congénital, lequel, après l'affiliation, dégénère et doit faire l'objet d'une ablation, ne commet pas une réticence, dès lors que son médecin-traitant ne l'avait jamais mise en garde contre les risques que cette excroissance pouvait représenter pour sa santé.
Extraído pela Omnilex
Whether the insured committed reticence by failing to disclose the congenital mole when applying for coverage.
No reticence can be admitted on these facts.
The insured had never been warned by her treating physician that the lesion posed a health risk, so the omission did not amount to a disclosable risk concealment in the sense of Art. 6 LCA.
Whether the insurer had to bear the full costs of the plastic and reconstructive part of the intervention.
Only 50% of the costs were chargeable to the insurer, because the insurer limited its coverage for plastic and reconstructive surgery and only half of the intervention fell into that category.
The court distinguished between the medically necessary ablation and the reconstructive graft; coverage was limited to the part qualifying as plastic/reconstructive surgery.
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