projekte
ATA/389/1997 ΓÇó Unjustified hospital stay only covered for one month
ATA/389/1997Cour de justice / Verwaltungskammer24.06.1997Partially Granted
An elderly person was placed in a clinic while awaiting a place in an appropriate long-term care institution. The court held that such a stay did not amount to economically justified treatment under Art. 23 LAMA and therefore could not be charged in full to the health insurer. However, the insurer still had to bear the costs for one month after it established that the hospitalisation was unjustified.
Art. 23 LAMA; economically justified treatment and scope of compulsory coverage for a clinic stay awaiting placement in a long-term care institution. A stay in a clinic undertaken merely as an interim solution pending availability of an appropriate institution does not constitute cost-effective treatment within the meaning of the statute and cannot be charged in full to the health insurer. Nevertheless, once the insurer has recognized the lack of justification for the hospitalisation, it remains liable for the costs for a transitional period of one month (consid. not stated).
Descripteurs
ASSURANCE SOCIALE; AM; SEJOUR A L'HOPITAL; ASSU
Normes
LAMA.23
Résumé
Placement d'une personne âgée en clinique en attendant qu'une place se libère dans un établissement adapté pour une prise en charge à long terme. Faute de constituer un traitement économique au sens de l'art. 23 LAMA, ce séjour injustifié ne peut être entièrement mis à charge de la caisse-maladie. Celle-ci devra néanmoins le prendre en charge durant un mois après qu'elle a constaté le caractère injustifié de cette hospitalisation.