Temporary coverage for unnecessary hospital stay

ATA/116/1997Tribunal de Justiça / Câmara Administrativa18 de fev. de 1997Granted

Extraído pela Omnilex

Resumo Omnilex

The case concerns health-insurance coverage for a hospital stay that was no longer medically justified. The court held that the insurer must nevertheless bear the costs for a transitional period of one month, because arrangements had still to be made for the insured person's transfer to a social institution. The decision applies the statutory rule on temporary continued coverage in such circumstances.

Sumário Omnilex

LAMA art. 12 al. 2; hospitalisation no longer medically justified but transfer to a social institution still to be arranged; the health insurer remains liable for a transitional period of one month. Where discharge cannot yet be implemented for organizational reasons linked to placement in a social institution, continued coverage is justified for a limited period despite the absence of current medical necessity.

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; SEJOUR A L'HOPITAL; ETABLISSEMENT HOSPITALIER; ECONOMIE DU TRAITEMENT; ASSU

Normes

LAMA.12 al.2

Résumé

La caisse-maladie doit couvrir une hospitalisation qui n'est plus justifiée pendant une période transitoire de un mois lorsque des dispositions doivent être prise en vue du transfert de l'interessé vers un établissement social.

Palavras-chave

social insurancehealth insurancehospitalizationtransitional periodtransfersocial institutioncoverage

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether the health insurer must continue to cover a medically unnecessary hospitalization for a transitional period of one month pending transfer to a social institution.

Decisão extraída

Yes. The insurer must cover the hospitalization for a transitional period of one month while steps are taken to arrange the transfer to a social institution.

Fundamentação extraída

Under the applicable social insurance rule, coverage is maintained temporarily when immediate discharge is not yet feasible because organizational measures for a suitable transfer still need to be taken.

Temporary coverage for unnecessary hospital stayGerado por IA