Disclosure duty and insurance reservation in social insurance

ATA/772/1997Tribunal de Justiça / Câmara Administrativa9 de dez. de 1997Dismissed

Extraído pela Omnilex

Resumo Omnilex

The appellant did not disclose past digestive disorders when completing the medical questionnaire for his new insurance. The court held that the insurer was therefore entitled to rely on the reservation and to refuse reimbursement for the expenses relating to those troubles.

Sumário Omnilex

LAMO art. 7; duty to disclose relevant pre-existing health conditions in the medical questionnaire for a new insurance contract. Where the insured omits affirmative disclosure of digestive disorders and the insurer later issues a reservation covering such ailments, expenses falling within the reserved risk need not be reimbursed. The decisive point is whether the omitted information was relevant to the reserved risk; if so, the refusal of benefits is consistent with the disclosure duty and the reservation (consid. not stated).

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; VIOLATION DE L'OBLIGATION D'ANNONCER; RESERVE D'ASSURANCE; PRINCIPE DE LA BONNE FOI; FRAIS(EN GENERAL); REDUCTION DE LA PRESTATION D'ASSURANCE; ASSU

Normes

LAMO.7

Résumé

Faute pour le recourant d'avoir répondu positivement à la question de savoir s'il avait souffert d'affections du système digestif lorsqu'il a rempli le questionnaire médical de sa nouvelle assurance, c'est avec raison que celle-ci ne lui a pas remboursé le coût des troubles tombant sous le coup d'une telle réserve.

Palavras-chave

social insuranceduty to discloseinsurance reservationgood faithbenefit reductionmedical questionnairecoverage exclusion

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether the insurer was entitled to rely on a reservation and refuse reimbursement for digestive-trouble expenses.

Decisão extraída

Yes. Because the appellant did not disclose his prior digestive complaints when answering the medical questionnaire, the insurer validly excluded coverage for those troubles.

Fundamentação extraída

The non-disclosure breached the duty to announce relevant health information. The expenses claimed fell within the scope of the reservation, so the refusal to reimburse was justified.

Disclosure duty and insurance reservation in social insuranceGerado por IA