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Unjustified hospital stay only covered for one month

ATA/389/1997Court of Justice / Administrative ChamberJun 24, 1997Partially Granted

Open source

Extracted by Omnilex

Omnilex summary

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.

Omnilex headnote

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).

Full text

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.

Keywords

social insurancehealth insurancehospital staylong-term careeconomic treatmentcoverage period

Extracted by Omnilex

Key legal questions extracted by Omnilex

Key legal question

Whether the clinic stay constituted economically justified treatment under Art. 23 LAMA and could be charged in full to the health insurer.

Extracted holding

The stay was not an economically justified treatment within the meaning of Art. 23 LAMA and could therefore not be charged entirely to the insurer.

Extracted reasoning

A placement in a clinic merely awaiting a suitable long-term care place does not qualify as cost-effective treatment covered without limit under the old health insurance statute.

Key legal question

For what period the health insurer remained liable after recognizing that the hospitalisation was unjustified.

Extracted holding

The insurer had to assume the costs for one month after it determined that the hospital stay was unjustified.

Extracted reasoning

Although the stay was not fully covered, the insurer remained liable for a transitional period of one month after its finding of unjustified hospitalisation.

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