ATA/616/1996•Causality assessed separately for each dental injury element
ATA/616/1996Tribunal de Justiça / Câmara Administrativa29 de out. de 1996Partially Granted
Extraído pela Omnilex
In an accident-insurance dispute concerning dental injuries, the court examined causal coverage separately for each damaged element. It denied accident causality for a badly damaged tooth because of insufficient care, but accepted causality for the fracture of the row of teeth supporting a bridge. The fact that the bridge had created a rupture line could not be held against the insured person, and irregular use of a mandibular appliance did not remove coverage, even if it may have contributed to weakening the prosthesis.
Art. 16 LAA; causal linkage for dental damage after an accident must be assessed item by item. Where several distinct dental structures are affected, accident causality may be admitted for one lesion and denied for another if the evidentiary and factual basis differs. A pre-existing weakness or insufficient care excludes causal attribution only for the damage element for which it is decisive. Conversely, a prosthetic arrangement or irregular appliance use does not sever causality where the accident-triggered fracture concerns a specifically identifiable structural break and the insured person cannot be reproached for the causally relevant configuration (consid. unspecified).
Descripteurs
ASSURANCE SOCIALE; ACCIDENT; AA; CHUTE; AFFECTION DENTAIRE; CAUSALITE; ASSU
Normes
LAA.16
Résumé
Examen détaillé de la causalité pour chaque élément du dommage : si celle-ci ne doit pas être admise dans le cas d'une dente très abîmée faute de soins, en revanche, tel doit être le cas de la fracture d'une rangée de dents soutenant un pont; le fait que la pose dudit pont avait crée un point de rupture en ligne, ne peut être reproché à l'assurée, pas plus que le port irrégulier d'un appareil mandibulaire (quand bien même cette négligence a pu entraîner une fragilisation de cette prothèse).
Extraído pela Omnilex
Whether accident causality must be assessed separately for each dental injury element.
Yes. Causality had to be examined individually for each damaged dental component.
The decision distinguishes between different dental elements and accepts causal coverage for some while denying it for others depending on the specific causal link shown.
Whether the badly damaged tooth remained accident-related despite lack of care.
No. Causality was not admitted for the heavily damaged tooth because of insufficient care.
The tooth's condition could not be attributed to the accident alone in light of the missing care.
Whether the fracture of the teeth supporting the bridge was accident-related.
Yes. The fracture of the row of teeth supporting the bridge was causally linked to the accident.
The bridge created a fracture line that could not be held against the insured person; the causal connection for this damage was therefore accepted.
Whether irregular use of the mandibular appliance broke the causal link.
No. Irregular use may have weakened the appliance, but this negligence could not be imputed to the insured person as breaking causality for the relevant damage.
The court held that the insured person could not be blamed for the bridge-related break line, and irregular wear of the mandibular appliance did not exclude causal coverage for the injury in question.
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