No adequate causal link for dental fracture after chewing

ATA/575/1998Tribunal de Justiça / Câmara Administrativa15 de set. de 1998Dismissed

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Extraído pela Omnilex

Resumo Omnilex

An insured person claimed accident insurance coverage for a fractured tooth after biting on a stone in a rice dish. The court upheld the denial of benefits, holding that the tooth had already been fissured and mechanically weakened. Because the tooth was so fragile that a fracture had to be expected during ordinary chewing, the incident did not establish an adequate causal connection for insurance purposes.

Sumário Omnilex

Art. 9 al. 1 OLAA; accident insurance coverage for dental injury requires a legally relevant accidental cause and an adequate causal link. Where a tooth is already fissured or otherwise markedly weakened, so that a fracture must be expected at any time during normal mastication, the subsequent breaking of the tooth during chewing is not attributable to an accident in the insured sense. The decisive factor is the pre-existing reduced mechanical resistance; the external event loses its adequate causal significance (consid. not specified).

Texto completo

Descripteurs

ASSURANCE SOCIALE; ACCIDENT; AA; CAUSALITE; AFFECTION DENTAIRE; FRACTURE; CAUSALITE ADEQUATE; PREDISPOSITION; REMBOURSEMENT DE FRAIS(ASSURANCE); ASSU

Normes

OLAA.9 al.1

Résumé

Confirmation de l'absence d'un lieu de causalité adéquat, la dent incriminée (un amalgame à teneur dentinaire) étant si faible qu'il fallait compter en tout temps avec une fracture lors d'un acte masticatoire normal. La cassure d'une dent, en raison de la présence d'un caillou dans un plat de riz, n'est pas un accident, dès lors qu'il a été prouvé que la dent était déjà fissurée et sa résistance mécanique très diminuée.

Palavras-chave

social insuranceaccident insurancecausal linkadequate causationdental injuryfracturepre-existing conditionreimbursement of expenses

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether the tooth fracture qualified as an accident under compulsory accident insurance.

Decisão extraída

No. The fracture was not treated as an accident because the tooth had already been fissured and its mechanical resistance was greatly reduced.

Fundamentação extraída

A pre-existing fissure and markedly diminished resistance meant that a fracture had to be expected at any time during ordinary mastication; the stone was therefore not the legally relevant accident cause.

Questão jurídica principal

Whether there was adequate causal connection between the chewing incident and the dental injury.

Decisão extraída

No adequate causal link existed.

Fundamentação extraída

The incriminated tooth was so weak that a fracture had to be expected even during normal chewing; the causal significance of the chewing incident was therefore not adequate.

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