ATA/548/1998•Health insurer not liable for accident-related rheumatic condition
ATA/548/1998Tribunal de Justiça / Câmara Administrativa1 de set. de 1998Dismissed
Extraído pela Omnilex
The appellant sought insurance coverage for a rheumatic condition linked to an accident that had occurred 15 years earlier. The court held that, under Art. 12 al. 2 LAMal, the health insurer had no duty to provide benefits for this condition and therefore rejected the claim.
Art. 12 al. 2 LAMal; accident-related condition and scope of health-insurance coverage: where the claimed rheumatic affliction is causally linked to an accident occurring many years earlier, the insurer is not obliged to grant benefits if the statutory conditions for coverage are not met. The decisive point is the absence of a current benefit obligation under the applicable insurance scheme; temporal remoteness of the accident does not by itself create coverage (consid. not indicated).
Descripteurs
ASSURANCE SOCIALE; AM; PRESTATION D'ASSURANCE(EN GENERAL); ASSU
Normes
LAMAL.12 al.2
Résumé
Dès lors que la recourante souffre d'affection rhumatismale due à un accident (survenu 15 ans auparavant), l'assureur-maladie n'est pas tenu à prestation.
Extraído pela Omnilex
Whether the health insurer must provide benefits for the appellant's rheumatic condition caused by a long-past accident.
The health insurer was not obliged to provide benefits.
The condition was attributable to an accident that occurred 15 years earlier, and under the applicable health-insurance rule the insurer had no duty to cover it.
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