ATA/702/1997•Health insurer must issue clear decision on hospital cost coverage
ATA/702/1997Tribunal de Justiça / Câmara Administrativa18 de nov. de 1997Partially Granted
Extraído pela Omnilex
The case concerns an insurer's refusal to continue covering hospital expenses. The court held that a health insurer does not have to pay for hospitalization that is not medically justified when the insured can receive the required treatment in another institution. However, the insurer may not suspend coverage merely by announcing that it will later obtain additional medical opinions. It must first issue a formal, clear, and unequivocal decision; in the meantime, it remains responsible for the related costs.
Art. 23 LAMA; hospital treatment and insurer's duty to decide clearly: medical necessity is a condition for cost coverage of hospitalization. Where the insured can obtain the required treatment in another establishment, the insurer may refuse to bear hospital expenses. Conversely, the insurer must exercise its decision-making power promptly and without ambiguity; a provisional announcement that a final position will be taken only after obtaining further medical opinions is insufficient. Until a formal and unequivocal decision is issued, the insurer remains bound to cover the related expenses (consid. not stated).
Descripteurs
ASSURANCE SOCIALE; AM; ECONOMIE DU TRAITEMENT; SEJOUR A L'HOPITAL; ETABLISSEMENT HOSPITALIER; ASSU
Normes
LAMA.23
Résumé
Les caisses ne doivent pas prendre en charge les frais d'une hospitalisation non justifiés médicalement, lorsque l'assuré peut recevoir les soins requis par son état de santé dans un autre établissement. Néanmoins, la caisse doit user à bon escient de son pouvoir de prendre une décision. On ne peut admettre qu'elle prenne une décision de ne plus prendre en charge, en indiquant parallèlement qu'elle va s'entourer d'autres avis médicaux, qu'elle obtient une année après. Il faut attendre d'elle une décision formelle et sans équivoque. Dans l'intervalle, elle doit prendre en charge l'ensemble des frais y relatifs.
Extraído pela Omnilex
Whether hospital expenses had to be covered despite the insurer's view that hospitalization was not medically necessary.
The insurer need not pay for a hospitalization that is not medically justified if the necessary treatment can be provided in another facility.
Coverage is not required for a hospital stay when the insured's condition can be treated appropriately elsewhere; medical necessity is the decisive criterion.
Whether the insurer could stop coverage by announcing that it would obtain additional medical opinions later.
No. The insurer had to issue a formal, unambiguous decision; until then, it had to continue covering all related expenses.
The insurer must exercise its decision-making power properly and cannot leave the insured in uncertainty while postponing a clear decision pending later medical reports.
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