ATA/723/1997•Discal hernia sequelae covered by health insurer, not accident insurer
ATA/723/1997Tribunal de Justiça / Câmara Administrativa25 de nov. de 1997Dismissed
Extraído pela Omnilex
The dispute concerned whether the sequelae of a disc hernia were covered by accident insurance after a fall. The court held that the fall could not have caused the hernia and therefore rejected accident coverage. As a result, the loss was to be borne by the health insurer rather than the accident insurer.
LAA art. 6; causal link between accident and disc hernia sequelae: accident coverage requires proof that the bodily condition was caused by the accident. Where the evidence does not establish that a fall could have triggered the herniation, the disability or treatment costs remain within sickness coverage and cannot be shifted to the accident insurer.
Descripteurs
ASSURANCE SOCIALE; ACCIDENT; AA; HERNIE DISCALE; ASSU
Normes
LAA.6
Résumé
Il incombe à l'assureur maladie et non accident de couvrir la suite d'une hernie discale qui n'a pu être provoquée par une chute.
Extraído pela Omnilex
Whether the accident insurer had to cover the sequelae of a disc hernia allegedly caused by a fall.
The disc hernia sequence was not shown to have been caused by the fall, so accident coverage was denied.
The court found that the fall could not be the cause of the disc hernia; therefore the condition fell outside accident insurance coverage.
Whether the health insurer had to bear the costs instead of the accident insurer.
Coverage lies with the health insurer, not the accident insurer.
Because the disc hernia was not attributable to an accident, the loss remained within sickness coverage.
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