ATA/7/1998•Accident insurance: remand for physical expertise, not psychiatric
ATA/7/1998Tribunal de Justiça / Câmara Administrativa13 de jan. de 1998Dismissed
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The Federal Insurance Court rejected the insurer's appeal. It held that the insured's complaints could not be treated as purely psychological, since they were at least partly caused by the fall. A psychiatric expertise was therefore not required. However, the remand to the insurer was upheld so that it could obtain an expert assessment of the physical, somatic symptoms under accident insurance law.
Art. 6 al. 1 LAA; accident causality and need for expert evidence: where post-accident complaints may include a psychological component but are at least partly attributable to the accident, the insurer may not deny causality solely for lack of psychiatric clarification. A psychiatric expertise is not mandatory if the decisive uncertainty concerns somatic consequences. If the file does not permit a reliable assessment of the bodily injury and its causal link, a remand for a physical expertise is appropriate (consid. not stated).
Descripteurs
ASSURANCE SOCIALE; ACCIDENT; AA; LESION DES TENDONS; TENDANCE A LA REVENDICATION; CAUSALITE NATURELLE; ATTEINTE A L'INTEGRITE; COUVERTURE; STATU QUO SINE; PHYSIOTHERAPIE; ACCIDENT ANODIN; AFFECTION PSYCHIQUE; ASSU
Normes
LAA.6 al.1
Résumé
L'intimée s'est dispensée à tort de soumettre l'assuré à une expertise psychiatrique, car les troubles dont il souffre, s'ils pourraient partiellement être d'ordre psychologique, ne sont pas moins partiellement la conséquence de la chute dont il a été victime. Le TFA a rejeté le recours de l'assurance mais confirmé le renvoi à celle-ci non pas pour effectuer une expertise psychiatrique, l'accident étant banal mais pour effectuer uen expertise relative aux symptômes physiques.
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Whether a psychiatric expertise was required to assess the insured's post-accident symptoms and causation.
No. The court held that the insurer was not required to order a psychiatric expertise on this record.
Although some symptoms may have a psychological component, they are at least partly a consequence of the accident. The dispute therefore did not justify a psychiatric examination as such.
Whether the case had to be remanded to the insurer for a physical expertise concerning the somatic symptoms.
Yes. The remand was upheld so that the insurer could obtain an expert assessment of the physical symptoms.
The available material was insufficient on the bodily consequences of the fall, so a somatic expertise remained necessary.
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