Reduction of daily allowances after medical adviser’s disagreement

ATA/162/1997Cour de justice / Chambre administrative4 mars 1997Confirmed

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Résumé Omnilex

The court held that the caisse rightly reduced the insured person’s daily allowances. The insurer’s medical adviser was entitled to dispute the work incapacity certificate issued by the treating physician, and the resulting reduction was therefore upheld.

Regeste Omnilex

Art. 57 LAMAL; medical adviser’s assessment versus treating physician’s certificate of incapacity for work; the insurer may rely on its medical adviser to challenge a work-incapacity certificate and adjust daily benefits accordingly where the medical evidence justifies doing so. The court will uphold the reduction if the adviser’s assessment is sufficiently convincing and the treating doctor’s certificate is not decisive by itself.

Texte intégral

Descripteurs

ASSURANCE SOCIALE; AM; MEDECIN-CONSEIL; CERTIFICAT MEDICAL; INCAPACITE DE TRAVAIL; ASSU

Normes

LAMAL.57

Résumé

C'est à juste titre que la caisse a réduit ses indemnités journalières car son médecin-conseil a contesté l'arrêt de travail du médecin-traitant.

Mots-clés

social insurancedaily allowancesmedical advisermedical certificatework incapacity

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Questions juridiques clés extraites par Omnilex

Question juridique clé

Whether the caisse was entitled to reduce daily allowances after its medical adviser challenged the treating physician’s certificate of incapacity for work.

Solution extraite

Yes. The reduction was upheld as justified on the basis of the medical adviser’s assessment.

Motifs extraits

The court accepted that the insurer could rely on its medical adviser to contest the treating physician’s work incapacity certificate and to reduce benefits accordingly.

Reduction of daily allowances after medical adviser’s disagreementGénéré par IA