projekte
ATA/85/1996 ΓÇó Good-faith reimbursement of a no-longer-covered medicine
ATA/85/1996Cour de justice / Verwaltungskammer13.02.1996
The case concerned a medicine that had ceased to be obligatorily reimbursed under health insurance. The court held that a convention between insurers and pharmacists requiring notice to customers did not bind insured persons, since they were not parties to it. If the insurer itself did not inform its insureds, it must bear the consequences of a pharmacist’s failure to warn when the insured could in good faith assume that coverage continued.
LAMA art. 12 para. 2 ch. 1 lit. c; reimbursement of a medicine no longer compulsorily covered by health insurance; the convention between insurers and pharmacists requiring information to customers does not bind insureds, who are not parties to it. Where the insurer has not informed its insureds and the insured could in good faith assume continued coverage, the insurer must bear the consequences of the lack of information and reimburse the costs, notwithstanding the pharmacist’s omission.
Descripteurs
ASSURANCE SOCIALE; AM; MEDICAMENT; PRINCIPE DE LA BONNE FOI; REMBOURSEMENT DE FRAIS(ASSURANCE); ASSU
Normes
LAMA.12 al.2 ch.1 litt.c
Résumé
Cas d'un médicament qui cesse d'être obligatoirement remboursé par les caisses-maladie. La convention liant les caisses et les pharmaciens, selon laquelle ces derniers doivent rendre leurs clients attentifs au fait que tels médicaments ne sont plus pris en charge par l'assurance, ne lie pas les assurés qui n'y sont pas partie. Par conséquent, il incombe à la caisse qui n'a pas informé ses assurés d'assumer la responsabilité d'un remboursement en cas de défaut d'information de la part du pharmacien, si l'assuré pouvait de bonne foi penser que le médicament en cause continuait à être pris en charge.