ATA/393/1998•No reimbursement for childbirth abroad under emergency exception
ATA/393/1998Tribunal de Justiça / Câmara Administrativa23 de jun. de 1998Dismissed
Extraído pela Omnilex
An insured woman who traveled to Tunisia while near term and gave birth there sought reimbursement from her Swiss health insurer. The court held that the circumstances did not amount to a reimbursable emergency under the applicable health insurance rule, since she remained abroad and delivered there for psychological reasons rather than being compelled by an emergency. The reimbursement claim was therefore denied.
OAMal art. 36 para. 2; reimbursement of medical treatment abroad in case of emergency: the exception is construed restrictively. A pregnant insured person who travels abroad shortly before delivery and remains there until childbirth for personal or psychological reasons cannot invoke an emergency within the meaning of the provision; the mere fact of an imminent birth abroad does not establish a reimbursable emergency absent an unforeseen medical necessity compelling treatment abroad.
Descripteurs
ASSURANCE SOCIALE; AM; GROSSESSE; ACCOUCHEMENT; URGENCE; ETAT ETRANGER; ASSU
Normes
OAMAL.36 al.2
Résumé
L'assurée enceinte qui se rend en Tunisie dans sa famille alors qu'elle est proche du terme de sa grossesse et qui y accouche (au lieu de rentrer en Suisse) pour des raisons psychologiques, n'a pas droit au remboursement de ses frais médicaux.
Extraído pela Omnilex
Whether medical expenses for childbirth in Tunisia must be reimbursed under the emergency exception.
No. The insured chose to remain abroad and give birth there for psychological reasons; this does not satisfy the conditions for reimbursement.
The stay abroad was not a qualifying emergency in the sense of the applicable health insurance rule, and the decision to remain until delivery prevented reimbursement.
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