ATA/534/1998•Allocation of arthroscopy and examination costs between insurers
ATA/534/1998Tribunal de Justiça / Câmara Administrativa1 de set. de 1998Partially Granted
Extraído pela Omnilex
The dispute concerned the allocation of medical costs between accident and health insurance. The court held that arthroscopy expenses had to be borne by the accident insurer, whereas examination expenses relating more to the insured person's constitutional condition were to remain with the health insurer. The case was therefore only partially successful for the insured person, depending on the cost item in question.
Art. 6 LAA; allocation of medical expenses between accident insurance and health insurance: costs of treatment directly attributable to the insured accident are chargeable to the accident insurer, whereas expenses for examinations primarily directed at determining or treating an underlying constitutional condition fall outside accident coverage and remain with the health insurer. The decisive criterion is the predominant causal and functional link of the medical service to the accident event; separate cost items must be assessed individually (cf. consid. not available).
Descripteurs
ASSURANCE SOCIALE; AM; ACCIDENT; AA; FRAIS(EN GENERAL); ASSU
Normes
LAA.6
Résumé
Frais d'arthroscopie mis à la charge de l'assureur-accident alors que les frais d'examen se rapportant plus à l'état constitutionnel de l'assurée sont mis à la charge de l'assureur-maladie.
Extraído pela Omnilex
Whether the arthroscopy costs had to be borne by the accident insurer.
The arthroscopy costs were charged to the accident insurer.
The procedure was sufficiently connected to the insured accident risk under Art. 6 LAA.
Whether the examination costs linked more to the insured person's constitutional condition had to be borne by the health insurer.
Those examination costs were allocated to the health insurer.
Costs relating mainly to the insured person's constitutional condition were not attributable to the accident insurer.
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