ATA/774/1998•Neutral medical expert required, not insurer’s consulting doctor
ATA/774/1998Tribunal de Justiça / Câmara Administrativa1 de dez. de 1998Confirmed
Extraído pela Omnilex
The court held that, after a prior judgment requiring the insurer to appoint an expert, the insurer could not designate one of its own consulting physicians to perform the expertise. Because the required medical assessment had to be neutral and complete, the file was sent back to the insurer for the appointment of an independent expert.
Art. 57 LAMal; when a court orders a medical expertise in a social insurance dispute, the expertise must be carried out by an independent and neutral expert. The insurer may not replace this evidentiary measure by using one of its own consulting physicians, since such a person lacks the required institutional independence. If the insurer fails to comply with this requirement, the file must be remitted for a proper full expertise by a neutral specialist.
Descripteurs
ASSURANCE SOCIALE; AM; EXPERTISE; MEDECIN-CONSEIL; EXPERT; HERNIE; INCAPACITE DE TRAVAIL; ASSU
Normes
LAMAL.57
Résumé
Suite à l'arrêt du TA exigeant de l'assurance qu'elle nomme un expert, celle-ci a cru bon de désigner à cette fin l'un de ses médecins-conseil. Le tribunal a dès lors renvoyé le dossier à l'assurance, afin qu'elle fasse procéder à une expertise complète par un expert neutre.
Extraído pela Omnilex
Whether the insurer could satisfy the court-ordered expert evidence by appointing one of its own consulting physicians.
No. A full medical expertise had to be carried out by a neutral expert.
An expert must be independent from the insurer when the court has ordered a proper expertise; a consulting physician of the insurer does not provide the required neutrality.
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