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Accident insurer bound by AI assessment of 50% invalidity

ATA/69/1997Court of Justice / Administrative ChamberJan 28, 1997Granted

Open source

Extracted by Omnilex

Omnilex summary

The insured, after a spinal injury, challenged the accident insurer's position on the extent of his earning incapacity. The court found that the insurer had no concrete medical or factual elements allowing it to deviate from the Geneva AI office's assessment of 50% invalidity. The final medical examination report did not undermine that assessment, and the insurer had not clarified whether any passivity of the insured affected the use of his residual earning capacity. The appeal was therefore allowed in substance.

Omnilex headnote

Art. 18 LAA; assessment of invalidity and residual earning capacity in accident insurance: an accident insurer may depart from an AI assessment only if it relies on concrete, case-specific elements capable of discrediting that assessment. Mere reservations based on the insured's attitude or limited motivation do not suffice. Where the medical file, including the insurer's own examination, does not establish that full-time work with full productivity is realistically possible, and the insurer fails to elucidate the effect of alleged passivity on the exploitation of residual earning capacity, the AI assessment retains probative force (consid. 2-4).

Full text

Descripteurs

LESION DE LA COLONNE VERTEBRALE; INCAPACITE DE GAIN; INDEMNITE POUR ATTEINTE A L'INTEGRITE; EVALUATION DE L'INVALIDITE; CAPACITE DE TRAVAIL PARTIELLE; ASSURANCE SOCIALE; ASSU

Normes

LAA.18

Résumé

"Le comportement du recourant, lors de son stage dans les ateliers protégés et en entreprise, n'est pas exemplaire. Il est fait expressément mention, dans les rapports y relatifs, à son manque de motivation qui pourrait ne pas rester sans influence sur l'appréciation que porte l'assuré de ses propres limites physiques. Malgré ces réserves, l'office AI du canton de Genève a arrêté à 50 % le degré d'invalidité du recourant. Le rapport d'examen médical final ne comporte aucun élément permettant de remettre en cause cette appréciation. En effet, les restrictions mises par le médecin d'arrondissement de l'intimée à une activité professionnelle à temps complet et avec un rendement total sont telles qu'il convient d'admettre que le recourant ne peut en fait travailler avec un tel rendement. L'assureur intimé n'a pas cherché à élucider la portée d'une éventuelle passivité du recourant sur la mise en oeuvre de sa capacité résiduelle de gain. A teneur de son dossier, on ne voit d'ailleurs pas de quels éléments concrets qui n'auraient pas été appréciés par l'office AI, l'assureur disposerait pour s'écarter de l'appréciation émise par cette office".

Keywords

accident insuranceinvalidityearning capacitymedical assessmentresidual capacityspinal injuryimpairment

Extracted by Omnilex

Key legal questions extracted by Omnilex

Key legal question

Whether the accident insurer could depart from the AI office's assessment of 50% invalidity and deny further benefits.

Extracted holding

The insurer had no concrete basis to depart from the AI office's assessment; the 50% invalidity rate remained decisive.

Extracted reasoning

The final medical report did not provide elements to call the assessment into question. The restrictions imposed by the insurer's district doctor were so significant that full-time work with full performance could not realistically be assumed. The insurer also failed to clarify any impact of the insured's alleged passivity on the use of residual earning capacity, and its file contained no concrete evidence overlooked by the AI office.

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