ATA/555/1998•Daily allowance based on collective contract, not individual certificate
ATA/555/1998Tribunal de Justiça / Câmara Administrativa1 de set. de 1998Modified
Extraído pela Omnilex
The dispute concerned the amount of a daily allowance under social insurance. Although an individual insurance certificate mentioned CHF 214 per day, the insured had been informed that the individual cover was concluded on the same terms as the collective contract. The court held that the contractual basis remained the collective contract. It further interpreted the overinsurance clause in the CGA to mean that the insurer must continue to supplement benefits until the insured has received compensation equal to 100% of the loss of earnings.
LAMAL art. 103; interpretation of CGA concerning overinsurance and daily allowances: where an individual certificate indicates a higher daily allowance, but the insured has been informed that the individual policy is concluded on the same terms as the collective contract, the certificate does not alter the contractual benefit basis. An overinsurance clause is construed according to its wording and purpose so that the insurer's duty to supplement benefits persists until the insured has received prestations corresponding to the full loss of earnings; benefits may be reduced or suspended only once that threshold is reached.
Descripteurs
ASSURANCE SOCIALE; AM; PERTE DE GAIN; INDEMNITE JOURNALIERE; PRINCIPE DE LA BONNE FOI; SURASSURANCE; ASSU
Normes
LAMAL.103
Résumé
Malgré un certificat d'assurance individuelle indiquant une indemnité journalière de CHF 214.-, l'indemnité due par l'assurance est celle qui était prévue dans le contrat collectif, l'assuré ayant été informé que l'assurance individuelle était conclue aux mêmes conditions que celles du contrat collectif. Interprétation des CGA traitant de la surindemnisation. In casu, l'assurance doit compléter ses prestations, selon ses CGA, dès lors que l'assuré n'a pas touché des indemnités atteignant le 100% de sa perte de gain.
Extraído pela Omnilex
How should the daily allowance be determined in light of the collective contract and the individual certificate?
The allowance is determined by the collective contract, not by the higher amount shown on the individual certificate.
The insured was informed that the individual insurance was concluded on the same conditions as the collective policy; the certificate could not override the contractual basis.
Whether the insurer must supplement its benefits under the overinsurance clause when the insured has not received benefits reaching 100% of the loss of earnings.
Yes. Under the CGA, the insurer must complete its benefits until the insured reaches full compensation of the loss of earnings.
The clause on overinsurance is interpreted so that the insurer continues to pay supplementary benefits so long as the insured has not obtained benefits amounting to 100% of the loss of earnings.
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