Dental costs not covered absent listed disease relation

ATA/721/1997Tribunal de Justiça / Câmara Administrativa25 de nov. de 1997Dismissed

Extraído pela Omnilex

Resumo Omnilex

The appellant sought reimbursement of dental expenses under a supplemental social insurance scheme. The insurer's regulation covered dental costs only when they were connected to a disease listed exhaustively in the policy rules. The cardiovascular condition relied on by the appellant was not on that list. The court therefore held that the contractual coverage condition was not met and rejected the reimbursement claim.

Sumário Omnilex

RALAMAL.34; dental expenses are reimbursable only if they are causally linked to a disease expressly included in the exhaustive list of covered conditions. Where the invoked ailment is not listed, coverage is excluded and no reimbursement can be claimed. The decisive point is the contractual delimitation of insured dental treatment by reference to a closed catalogue of diseases; absent inclusion in that catalogue, the insurer has no duty to pay (consid. implied by the summary).

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; AFFECTION DENTAIRE; ASSURANCE COMPLEMENTAIRE; ASSURANCE POUR SOINS DENTAIRES; ASSU

Normes

RALAMAL.34

Résumé

Dès lors que les frais dentaires sont pris en charge, selon le règlement de l'assurance, lorsqu'ils sont en relation à une des maladies faisant partie d'une liste exhaustive et que l'affection cardio-vasculaire n'y figure pas, le recourant ne peut obtenir le remboursement de ses frais dentaires.

Palavras-chave

social insurancedental treatmentsupplemental insurancecoverage exclusionexhaustive listreimbursementcardiovascular disease

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether dental treatment costs are reimbursable under the supplemental insurance regulations when the underlying disease is not on the exhaustive list.

Decisão extraída

No. Because the relevant cardiovascular condition is not included in the exhaustive list of diseases covered by the regulation, the claimant cannot obtain reimbursement of the dental expenses.

Fundamentação extraída

The regulation conditions coverage on a connection to one of the listed diseases, and the list is exhaustive. Since the cardiovascular disease invoked by the appellant is not among the listed conditions, the contractual coverage requirement is not met.

Dental costs not covered absent listed disease relationGerado por IA