ATA/328/1995•Daily indemnity and medical assessment; remand for new decision
ATA/328/1995Court of Justice / Administrative ChamberJun 20, 1995Partially Granted
Extracted by Omnilex
The administrative court accepted the treating physician's assessment of the insured person's incapacity for work because the other physicians consulted were not ophthalmology specialists. It held incapacity to work established until 10 February 1995. For the period after that date, the court found the file insufficient to decide and remanded the matter to the caisse for a new decision.
LAMA art. 12 bis al. 1; assessment of work incapacity in daily-indemnity disputes; evidentiary value of medical opinions. The court may rely on the treating physician where opposing medical assessments are not issued by specialists in the relevant field. If the file does not permit a reliable determination of work capacity beyond a given date, the claim is to that extent remanded to the insurer for fresh assessment and decision; the court may not substitute its own judgment for unresolved medical questions (consid. not stated).
Descripteurs
ASSURANCE SOCIALE; AM; INDEMNITE JOURNALIERE; DOSSIER MEDICAL; DECISION DE RENVOI
Normes
LAMA.12 bis al.1
Résumé
Le TA a suivi l'avis médical du médecin traitant de l'assuré dès lors que les autres médecins consultés n'étaient pas des spécialistes en ophtalmologie. Incapacité de travail admise jusqu'au 10 février 1995. Dossier renvoyé à la caisse pour nouvelle décision dès cette date, le TA n'étant plus en mesure de trancher de la capacité de travail de l'assuré, vu la base du dossier en sa possession.
Extracted by Omnilex
Whether the insured person's work incapacity was established for daily-indemnity purposes until 1995-02-10.
Work incapacity was accepted until 1995-02-10, based on the treating physician's view and the lack of ophthalmology expertise among the other consulted doctors.
The court gave decisive weight to the treating physician's assessment because the contrary medical opinions were not issued by ophthalmology specialists.
Whether the matter had to be remanded to the caisse for a new decision after 1995-02-10.
Yes. The court could no longer determine the insured person's work capacity on the file available and therefore sent the case back for a new decision from that date onward.
The evidentiary basis before the court was insufficient to rule definitively on work capacity beyond 1995-02-10.
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