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No concealment of isolated back pain in health insurance admission

ATA/86/1997Court of Justice / Administrative ChamberFeb 4, 1997Dismissed

Open source

Extracted by Omnilex

Omnilex summary

The insured had experienced back pain twice about seven to eight years before completing an admission form for a different health insurer. The court held that the episodes were isolated, quickly resolved, and followed by a long period without complaints or work incapacity. In these circumstances, omitting them from the admission form did not amount to concealment or a breach of the duty to disclose, and the insured remained in good faith.

Omnilex headnote

LAMal 12; obligation to disclose health information on admission to insurance and concept of concealment. An insured person does not act deceptively by omitting remote, isolated and promptly resolved back-pain episodes where the complaints were followed by a long symptom-free period and no continuing impairment was apparent. The decisive factor is whether, according to good faith, the omitted facts were objectively significant and recognizable as relevant health history; sporadic, banal and long-past ailments may be disregarded without breach of the duty to announce (consid. not specified).

Full text

Descripteurs

ASSURANCE SOCIALE; AM; LESION DE LA COLONNE VERTEBRALE; VIOLATION DE L'OBLIGATION D'ANNONCER; PRINCIPE DE LA BONNE FOI; ASSU

Normes

LAMAL.12

Résumé

L'assuré qui a souffert à deux reprises de mal de dos sept ans avant de remplir une formule d'admission dans une autre caisse-maladie, ne commet pas une réticence en ne les mentionnant pas. En effet, les épisodes douloureux ont pu être rapidement réglés et apparaissent comme des événements isolés. L'assurée était donc de bonne foi. Ne commet pas une réticence l'assurée qui ne signale pas, lors de son admission à sa caisse-maladie, qu'elle a subi huit ans auparavant des douleurs dorsales ayant donné lieu à des radiographies et à douze séances de physiothérapie, dans la mesure où ces douleurs ont été suivies d'une longue période de répi, sans interruption de travail, hormis une nouvelle manifestation de banales douleurs lombaires quelques années plus tard.

Keywords

social insurancehealth insuranceback painnon-disclosuregood faithconcealment

Extracted by Omnilex

Key legal questions extracted by Omnilex

Key legal question

Whether failing to disclose earlier, isolated back pain episodes when joining a health insurer constituted concealment or breach of the duty to declare.

Extracted holding

No. The prior complaints were isolated, could be resolved quickly, and were followed by a long symptom-free period; the insured therefore acted in good faith.

Extracted reasoning

Because the earlier pain episodes were remote in time and did not indicate a continuing condition, the insured was not required to mention them as relevant health history.

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