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Daily allowances limited to seven months before suspension

ATA/110/1996Court of Justice / Administrative ChamberMar 5, 1996Modified

Open source

Extracted by Omnilex

Omnilex summary

The dispute concerned the duration of daily sickness-insurance benefits owed to a 56-year-old manual construction worker with only elementary schooling. The lower court limited the insurer's duty to pay daily allowances, and the Federal Insurance Court confirmed the need to give the insured sufficient time to find suitable work before suspension. It fixed the payment period at seven months starting 1995-07-16, reflecting the insured's age, occupational background, and limited education.

Omnilex headnote

LAMA art. 12 bis; duty to mitigate loss in daily-allowance insurance and time allowed before suspension of benefits: the insured must be granted a sufficient adaptation period to seek suitable employment before indemnities are discontinued. In assessing that period, account may be taken of age, professional background, and schooling. Where the insured has long performed unskilled manual labour and has limited education, a shorter but still adequate transition period may be fixed; the measure is discretionary and reviewed for abuse or excess of discretion (consid. implied).

Full text

Descripteurs

ASSURANCE SOCIALE; AM; INDEMNITE JOURNALIERE; INCAPACITE DE TRAVAIL; OBLIGATION DE REDUIRE LE DOMMAGE; LIMITATION; DOMMAGE

Normes

LAMA.12 bis

Résumé

"Ainsi, compte tenu de l'âge du recourant (56 ans), du fait qu'il a toujours travaillé comme manoeuvre dans le bâtiment et qu'il a été scolarisé jusqu'à l'âge de 11 ans, le TA fixera à sept mois, dès le 16 juillet 1995, la durée pendant laquelle la caisse devra verser des indemnités journalières. Cependant, le TFA a précisé qu'un laps de temps suffisant devait être imparti à l'assuré avant que l'indemnité journalière ne soit suspendue pour permettre à cet assuré de trouver un travail adéquat (RJAM 1982 p. 78; Jean-Louis DUC, Statut des invalides dans l'assurance maladie d'une indemnité journalière, Revue suisse des assurances sociales et de la prévoyance professionnelles, 1987, p. 179.)".

Keywords

social insurancedaily allowanceincapacity for workduty to mitigate lossbenefit suspensiondamage limitation

Extracted by Omnilex

Key legal questions extracted by Omnilex

Key legal question

How long the insurer had to pay daily allowances before suspension in light of mitigation duties and the insured's personal circumstances.

Extracted holding

The court fixed the payment period at seven months starting on 1995-07-16, and emphasized that the insured must be given sufficient time to find suitable work before benefits are suspended.

Extracted reasoning

Given the insured's age, long-standing manual work in construction, and limited schooling, the lower court could set a limited period for continued payment; however, the insured must still be afforded a sufficient transition period to secure appropriate employment.

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