Retroactive premium increase valid with timely notice

ATA/315/1997Tribunal de Justiça / Câmara Administrativa27 de mai. de 1997Confirmed

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Extraído pela Omnilex

Resumo Omnilex

The court upheld an insurer's right to demand retroactive payment of additional premiums where premiums had been fixed too low because of an erroneous assessment of future health-care cost increases, provided the insureds were informed sufficiently and in time. It further held that notice communicated three days before the cancellation deadline was adequate. A valid resignation did not depend on prior affiliation with another health insurer or proof of such affiliation.

Sumário Omnilex

LAMO. 10 al. 1, 11; retroactive premium supplement and termination of health insurance relationship. An insurer may, in conformity with the law and the principle of equal treatment, claim additional premiums retroactively for a defined period when premiums had been set too low owing to an incorrect assessment of cost developments, provided the insureds were informed in a manner that was both sufficient and timely. Notification three days before the cancellation deadline is adequate for this purpose. A valid cancellation is not subject to proof of affiliation with another health insurer; such affiliation is not a constitutive condition of termination.

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; ACCIDENT; AA; AFFILIATION; ASSURANCE INDIVIDUELLE; ASSUREUR; AUGMENTATION(EN GENERAL); PRIME D'ASSURANCE; SUPPLEMENT DE PRIME; RESILIATION; DELAI; RETROACTIVITE; ASSU

Normes

LAMO.10 al.1; LAMO.11

Résumé

Conformément à la loi et au principe de l'égalité de traitement, une assurance maladie et accidents peut réclamer un paiement rétroactif pour des primes fixées trop bas pour une période donnée (en raison d'une erreur d'appréciation sur le renchérissement des coûts de la santé), dès l'instant où ses assurés ont été informés de manière satisfaisante et en temps utile (ATFA du 2 août 1996). La notification d'une telle décision trois jours avant le délai de résiliation est suffisant, l'affiliation à une autre caisse-maladie et la preuve de cette affiliation ne constituant pas une condition de la validité d'une démission. Conformément à la loi et au principe de l'égalité de traitement, une assurance maladie et accidents peut réclamer un paiement rétroactif pour des primes fixées trop bas pour une période donnée (en raison d'une erreur d'appréciation sur le renchérissement des coûts de la santé), dès l'instant où ses assurés ont été informés de manière satisfaisante et en temps utile (ATFA du 2 août 1996). La notification d'une telle décision trois jours avant le délai de résiliation est suffisant, l'affiliation à une autre caisse-maladie et la preuve de cette affiliation ne constituant pas une condition de la validité d'une démission.

Palavras-chave

social insurancehealth insurancepremium increaseretroactivityterminationcancellation deadlineequal treatmentnotice

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether an insurer may demand retroactive payment of additional premiums after setting premiums too low due to an error in cost assessment.

Decisão extraída

Yes, retroactive recovery is permissible if the insureds were informed adequately and in due time.

Fundamentação extraída

Under the law and the principle of equal treatment, an insurer may correct premiums that were set too low for a given period when the underpricing resulted from an erroneous assessment of health-cost inflation, provided the insured persons received sufficient and timely notice.

Questão jurídica principal

Whether notice given three days before the cancellation deadline is sufficient for a valid termination of the insurance relationship without proof of affiliation to another insurer.

Decisão extraída

Yes, notice three days before the deadline is sufficient, and proof of affiliation with another health insurer is not a validity requirement for the termination.

Fundamentação extraída

The court held that timely notification was enough to allow termination; neither prior affiliation to another insurer nor proof of such affiliation was required as a condition for a valid resignation.

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