ATA/72/1998•Health insurer must advance benefits pending causation finding
ATA/72/1998Tribunal de Justiça / Câmara Administrativa10 de fev. de 1998Granted
Extraído pela Omnilex
The court held that where it is not yet settled whether medical expenses are causally connected to an accident, the health insurer must advance the insured benefits. The unresolved causation issue does not allow the insurer to withhold payment pending clarification.
OAMal 112 al. 1; lorsque le lien de causalité entre les frais médicaux et l’accident n’est pas encore tranché, l’assureur-maladie est tenu d’avancer les prestations assurées. Le mécanisme d’avance s’impose tant que l’imputabilité des frais à l’accident demeure incertaine, afin d’éviter une lacune de couverture; la clarification ultérieure de la causalité détermine ensuite la charge définitive de l’assurance tenue de prester.
Descripteurs
ASSURANCE SOCIALE; ACCIDENT; AA; PRESTATION D'ASSURANCE(AA); AVANCE(EN GENERAL); ASSU
Normes
OAMAL.112 al.1
Résumé
Dès lors que la question du lien de causalité entre les frais médicaux et l'accident n'est pas résolue, il incombe à l'assureur-maladie d'avancer les prestations assurées par lui.
Extraído pela Omnilex
Whether the health insurer must advance insured benefits while causation between the medical expenses and the accident remains unresolved.
Yes. Until the causal link is determined, the health insurer must advance the benefits covered by it.
Because the question whether the medical expenses are causally linked to the accident has not yet been resolved, the advance-payment mechanism applies to avoid a gap in coverage.
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