ATA/426/1998•False information in health insurer prospectus, but no proven damage
ATA/426/1998Tribunal de Justiça / Câmara Administrativa28 de jul. de 1998Dismissed
Extraído pela Omnilex
The court held that incorrect information in a health insurer’s prospectus can be relied upon against the insurer. However, the appellants failed to show any damage resulting from the challenged decision, since the premiums did not increase. The court further stated that once the deductibles increased automatically, the appellants were entitled to change insurer within the deadline of Art. 7(2) LAMal. The appeal was therefore dismissed.
Art. 64 al. 1 LAMal; misleading statements in a health insurer’s prospectus are opposable to the insurer, but civil or insurance-law relief requires proof of concrete damage. Where the premiums remain unchanged, no compensable loss is established. The automatic increase of the franchise does not itself create damage; it may, however, trigger the insured’s statutory right to change insurer within the period of Art. 7 al. 2 LAMal (consid. no specified).
Descripteurs
ASSURANCE SOCIALE; AM; PRIME D'ASSURANCE; AUGMENTATION(EN GENERAL); AFFILIATION; FRANCHISE(ASSURANCE); TARIF(EN GENERAL); MODIFICATION(EN GENERAL); PRINCIPE DE LA BONNE FOI; ASSU
Normes
LAMAL.64 al.1
Résumé
Des informations contraires à la loi contenues dans le prospectus d'une caisse-maladie lui sont opposables. Or, les recourants n'ont pas démontré en quoi la décision de la caisse leur causait un dommage, les primes n'ayant pas augmenté. A compter du jour de l'augmentation automatique des franchises, les recourants étaient en droit de changer d'assureur dans le délai de l'article 7 alinéa 2 LAMal.
Extraído pela Omnilex
Whether incorrect information in a health insurer's prospectus is opposable to the insurer under LAMal Art. 64(1).
The insurer is bound by information in its prospectus even if it is contrary to the law.
The court accepted that unlawful statements in the prospectus could be relied upon against the insurer.
Whether the appellants proved a compensable damage from the insurer's decision.
No compensable damage was shown because the premiums had not increased.
The appellants did not demonstrate that the challenged decision caused them a financial loss.
Whether the appellants could switch insurer once the deductible increase took effect automatically.
From the day of the automatic increase of the deductibles, the appellants were entitled to change insurer within the time limit of Art. 7(2) LAMal.
The automatic increase triggered the statutory right to terminate or switch insurer within the prescribed period.
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