ATA/629/1998•Medical adviser opinion is not an expert report
ATA/629/1998Tribunal de Justiça / Câmara Administrativa6 de out. de 1998Not Examined
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In a dispute concerning daily sickness benefits under the LAMal, the court held that a medical opinion issued by the insurer’s medical adviser cannot be equated with a formal expert report. It further held that a contrary opinion from the treating physician does not, by itself, suffice to call the adviser’s view into question. The extract provided only states these evidentiary principles and does not disclose the final operative disposition of the case.
Art. 72 LAMal; valeur probante des avis médicaux en matière d’indemnité journalière; l’avis du médecin-conseil de l’assureur ne constitue pas une expertise au sens procédural. Le médecin-conseil agit comme organe d’appréciation interne de l’assureur et non comme expert indépendant. L’avis du médecin traitant, compte tenu de sa relation thérapeutique, ne suffit pas, à lui seul, à renverser une appréciation contraire du médecin-conseil. L’autorité apprécie librement les preuves selon leur force probante respective et non selon le seul statut du médecin (consid. non indiqué).
Descripteurs
ASSURANCE SOCIALE; AM; MEDECIN-CONSEIL; EXPERTISE; INDEMNITE JOURNALIERE; ASSU
Normes
LAMAL.72
Résumé
Un avis médical émis par le médecin-conseil de l'assurance ne saurait être considéré comme un rapport d'expertise. L'avis du médecin-traitant n'est pas de nature à remettre en cause celui, contraire, du médecin-conseil.
Extraído pela Omnilex
Whether the medical opinion of the insurer’s medical adviser can be treated as an expert report.
No. The adviser’s opinion is not equivalent to an expert report.
A medical adviser engaged by the insurer does not provide an independent expert assessment in the procedural sense.
Whether the treating physician’s contrary opinion is sufficient to displace the medical adviser’s assessment.
No. The treating physician’s opinion does not, by itself, overturn the contrary opinion of the insurer’s medical adviser.
The court held that the treating doctor’s status alone does not make the opinion decisive against the adviser’s assessment.
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