projets
ATA/300/1997 ΓÇó Conflict between insurer and disability assessment
ATA/300/1997Cour de justice / Chambre administrative15 mai 1997Remanded
The case concerned social insurance daily benefits. The caisse concluded that the insured person had full work capacity, whereas the disability insurance authority found 85% disability. The court held that such a major discrepancy could not be ignored. It annulled the caisse’s decision and remanded the file for further examination.
LAMA 12 bis al. 1; where the competent insurer’s assessment of work capacity is in marked contradiction with the disability insurance authority’s assessment, the divergence cannot be disregarded. Such a substantial inconsistency requires annulment of the insurer’s decision and remand for renewed assessment; the authority must resolve the evidentiary conflict before deciding on entitlement to daily benefits.
Descripteurs
ASSURANCE SOCIALE; AM; INDEMNITE JOURNALIERE; ASSU
Normes
LAMA.12 bis al.1
Résumé
Il y a en l'espèce un tel écart entre la décision de la caisse, qui conclut à la pleine capacité de travail de l'assuré, et celle de l'AI, qui conclut à une invalidité de 85 %, que l'on n'en saurait faire abstraction. La décision de la caisse doit être annulée et le dossier doit lui être renvoyé.