Health insurer could not rely on administrative delays alone

ATA/566/1998Tribunal de Justiça / Câmara Administrativa15 de set. de 1998Partially Granted

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Extraído pela Omnilex

Resumo Omnilex

The health insurer denied benefits for loss of salary, arguing in essence that the accident insurer had proceeded too slowly. The court held that such administrative delays alone did not justify a refusal of insurance prestations. The appeal was therefore upheld in substance and the matter remanded to the respondent for reconsideration on the merits.

Sumário Omnilex

Art. 72 al. 2 LAMal; refusal of benefits for loss of salary may not be justified solely by delays attributable to another insurer’s administrative handling. The health insurer must examine the insured’s entitlement according to the substantive statutory conditions and cannot replace this assessment by a reference to procedural slowness. Where the refusal lacks such substantive grounds, the case must be remitted for a new decision (consid. unspecified).

Texto completo

Descripteurs

ASSURANCE SOCIALE; ACCIDENT; AA; CAUSALITE; INDEMNITE JOURNALIERE; LESION DE LA COLONNE VERTEBRALE; INCAPACITE DE TRAVAIL; AM; PRESTATION; REFUS DE LA PRESTATION D'ASSURANCE; ASSU

Normes

LAMAL.72 al.2

Résumé

L'assurance-maladie intimée ne peut se contenter de souligner les lenteurs administratives dont a fait preuve l'assurance accident du recourant, pour justifier son refus d'octroi de prestations pour perte de salaire. Par conséquent, l'affaire est renvoyée à l'intimée.

Palavras-chave

social insuranceaccidentcausationdaily allowancespinal injurywork incapacitybenefits refusalremand

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether the health insurer could refuse benefits for loss of salary solely because the accident insurer had handled the matter slowly.

Decisão extraída

No. Administrative delays by the accident insurer were not sufficient, by themselves, to justify refusing insurance benefits for loss of salary.

Fundamentação extraída

The insurer had to assess the entitlement on the substantive conditions for benefits. Mere reference to procedural slowness in the accident-insurance file did not establish a valid basis for denial.

Questão jurídica principal

Whether the matter should be remanded to the respondent for a new decision.

Decisão extraída

Yes. The case was sent back to the respondent for reconsideration.

Fundamentação extraída

Because the refusal was not adequately justified, the insurer had to re-examine the claim and decide again on the merits.

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