Dental reconstruction costs reimbursable for osteomyelitis treatment

ATA/251/1998Tribunal de Justiça / Câmara Administrativa5 de mai. de 1998Granted

Extraído pela Omnilex

Resumo Omnilex

The case concerned reimbursement under mandatory health insurance for dental expenses linked to osteomyelitis. The court held that when dental treatment is medically required to treat that condition, the insurer must cover not only sanitation costs but also reconstruction costs. The appellant therefore obtained reimbursement for the broader set of dental expenses.

Sumário Omnilex

Art. 31 LAMal; when dental treatment is medically necessary for the treatment of osteomyelitis, the mandatory health insurer's reimbursement duty is not confined to sanitation measures but also extends to reconstruction expenses. The decisive criterion is the medical necessity of the dental intervention as part of the causal treatment of the covered disease; once that necessity is established, the insurer must assume the related dental costs in their entirety (consid. not specified).

Texto completo

Descripteurs

ASSURANCE SOCIALE; AFFECTION DENTAIRE; REMBOURSEMENT DE FRAIS(ASSURANCE); ASSURANCE OBLIGATOIRE; LIMITATION; SOINS MEDICAUX; PRESTATION OBLIGATOIRE; TRAITEMENT(EN GENERAL); PRESTATION D'ASSURANCE(EN GENERAL); ASSU

Normes

LAMAL.31

Résumé

Dans les cas où le traitement de l'ostéomyélite, dont souffre le recourant, exige des soins dentaires, l'obligation de remboursement de l'assureur s'étend non seulement aux frais d'assainissement, mais également à ceux de reconstruction.

Palavras-chave

social insurancedental treatmentreimbursement of costsmandatory insurancemedical necessityreconstruction costs

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether mandatory health insurance must reimburse not only dental sanitation costs but also reconstruction costs when dental care is required to treat osteomyelitis.

Decisão extraída

Yes. If the treatment of osteomyelitis requires dental care, the insurer's duty to reimburse extends to both sanitation and reconstruction expenses.

Fundamentação extraída

Dental treatment that is medically necessary as part of the treatment of osteomyelitis falls within the insurer's reimbursement obligation; that obligation is not limited to sanitation work alone.

Dental reconstruction costs reimbursable for osteomyelitis treatmentGerado por IA