Insurer remained liable for daily benefits despite disputed medical certificates

ATA/526/1998Tribunal de Justiça / Câmara Administrativa1 de set. de 1998Dismissed

Extraído pela Omnilex

Resumo Omnilex

The dispute concerned daily sickness benefits under social insurance law. The insurer refused to continue payment, relying on its medical adviser’s view that the treating physician’s incapacity certificates were not credible. The court held that the insurer had not properly disproved the insured’s incapacity to work and had not sufficiently investigated the matter. A mere general criticism of the treating physician’s practice was insufficient. The insurer therefore remained bound to pay the daily indemnity.

Sumário Omnilex

LAMA 12; indemnité journalière; preuve de l’inaptitude au travail: l’assureur qui entend refuser ou cesser le versement doit établir, au terme d’une instruction adéquate, l’inanité des certificats d’incapacité de travail du médecin traitant. Le médecin-conseil ne saurait se limiter à contester ces certificats par une appréciation abstraite ou générale de la manière dont le praticien délivrerait des arrêts de travail; une telle critique ne suffit pas à renverser la valeur probante des attestations médicales. À défaut d’une instruction complète et convaincante, l’assureur demeure tenu au paiement de l’indemnité journalière.

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; INDEMNITE JOURNALIERE; MEDECIN-CONSEIL; MEDECIN TRAITANT; PREUVE; CONSTATATION DES FAITS; ASSU

Normes

LAMA.12

Résumé

Faute par l'assurance d'avoir prouvé l'inanité des certificats d'incapacité de travail du médecin-traitant de l'assuré, en instruisant correctement le cas, elle reste tenue au paiement de l'indemnité journalière. En particulier, le médecin-conseil ne pouvait se borner à contester le certificat médical du médecin-traitant, au seul motif que celui-ci ne serait pas sérieux dans la manière de délivrer des arrêts de travail.

Palavras-chave

social insurancedaily allowancemedical evidenceburden of prooftreating physicianmedical adviserwork incapacity

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether the insurer proved that the treating physician's incapacity certificates were unreliable and thus could deny daily benefits.

Decisão extraída

No. The insurer had to prove the certificates were unfounded by properly investigating the case; it failed to do so and remained bound to pay daily benefits.

Fundamentação extraída

The medical adviser could not merely dispute the treating physician's certificate by asserting, without proper investigation, that the physician was not serious in issuing work-incapacity certificates.

Insurer remained liable for daily benefits despite disputed medical certificatesGerado por IA