Health insurance coverage for rehabilitation treatment abroad

ATA/771/1997Tribunal de Justiça / Câmara Administrativa9 de dez. de 1997Dismissed

Extraído pela Omnilex

Resumo Omnilex

The insured sought coverage from his health insurer for rehabilitation treatment undergone in France after a knee lesion. The court held that the treatment was not an emergency and that comparable care was available in Switzerland. It therefore denied mandatory coverage under Art. 34(2) LAMal and dismissed the appeal.

Sumário Omnilex

Art. 34 al. 2 LAMal; coverage of treatment abroad; non-urgent rehabilitation may be excluded where equivalent treatment is available in Switzerland. Mandatory health insurance does not have to assume costs for planned foreign treatment that is neither emergency care nor otherwise justified by unavailability of appropriate care at home. The decisive factors are the absence of urgency and the objective possibility of obtaining the medically indicated treatment in Switzerland; a subjective preference for foreign treatment is insufficient. Good-faith considerations do not override the statutory limitation on foreign coverage in the absence of specific assurances.

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; COUVERTURE; LESION DU GENOU; ASSUREUR; PRINCIPE DE LA BONNE FOI; CONTROLE MEDICAL; ETAT ETRANGER; ASSU

Normes

LAMAL.34 al.2

Résumé

Faute de constituer un traitement d'urgence, un traitement de rééducation subi en France n'a pas a être couvert par l'assurance-maladie du recourant, ce d'autant que de tels soins pouvaient être prodigués en Suisse.

Palavras-chave

social insurancehealth insuranceforeign treatmentrehabilitationemergency treatmentgood faithmedical coverageknee injury

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether rehabilitation treatment received in France had to be covered by compulsory health insurance under Art. 34(2) LAMal.

Decisão extraída

No. Because the treatment was not an emergency and the relevant care could also be provided in Switzerland, the insurer had no duty to cover it.

Fundamentação extraída

Art. 34(2) LAMal does not require coverage for non-urgent treatment abroad when equivalent treatment is available domestically. The good-faith argument did not alter this result on the facts described.

Health insurance coverage for rehabilitation treatment abroadGerado por IA