ATA/289/1996•Social insurance disclosure duty and retroactive reservation
ATA/289/1996Tribunal de Justiça / Câmara Administrativa21 de mai. de 1996Confirmed
Extraído pela Omnilex
The administrative court held that the insured person breached the duty to disclose by omitting prior varicose-vein treatment when completing the affiliation questionnaire. Even if she believed that treatment older than five years did not need to be reported, no such limitation appeared in the questionnaire or the insurer's general conditions. The insurer was therefore entitled to place a retroactive reservation for varicose veins.
LAMA. 5; duty to disclose in affiliation questionnaires and retroactive reservation for pre-existing conditions. A person seeking affiliation must answer truthfully and completely to questions concerning prior illnesses or treatment. An alleged time limit for disclosure cannot be inferred from the insured's subjective understanding where neither the questionnaire nor the insurer's general conditions contain such a restriction. Failure to disclose a relevant pre-existing ailment constitutes a misrepresentation justifying a retroactive reservation for the undisclosed condition.
Descripteurs
ASSURANCE SOCIALE; VIOLATION DE L'OBLIGATION D'ANNONCER; DELAI; AM; ASSU
Normes
LAMA.5
Résumé
Le Tribunal administratif a considéré que l'assurée avait commis une réticence en remplissant le questionnaire d'affiliation sans mentionner qu'elle avait souffert cinq ans auparavant de varices, pour lesquelles elle avait été soignée. Quand bien même l'assurée aurait imaginé qu'il n'était pas nécessaire de mentionner les traitements remontant à plus de cinq ans, un tel délai ne ressortait nullement du questionnaire ni des conditions générales de la caisse. Celle-ci était donc en droit de constituer une réserve rétroactive pour varices.
Extraído pela Omnilex
Whether failing to disclose prior varicose-vein treatment in the affiliation questionnaire breached the duty to report.
Yes. The omission constituted a breach of the disclosure obligation.
The questionnaire required full disclosure, and neither the form nor the insurer's general conditions provided any five-year time limit for reporting prior treatment.
Whether the insurer was entitled to enter a retroactive reservation for varicose veins.
Yes. The insurer could validly impose the reservation retroactively.
Because the insured person failed to disclose a relevant pre-existing condition, the insurer was justified in protecting itself by a retroactive reservation.
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