ATA/361/1995•Expertise costs borne by insurer; irresistible impulse not tied to criminal irresponsibility
ATA/361/1995Tribunal de Justiça / Câmara Administrativa3 de jul. de 1995Confirmed
Extraído pela Omnilex
The Federal Court dealt with a social-insurance dispute concerning expert evidence costs and the assessment of an insured person's capacity to act reasonably after a suicide-related event. It held that the insurer had not sufficiently investigated the case, so the costs of the expertise had to be borne by the insurance. The court further stated that total incapacity to act reasonably is not to be assessed by reference to criminal-law irresponsibility under Art. 10 SCC. On the basis of the medical expertise, the insured person was found incapable of acting reasonably, and the insurer could not depart from those conclusions.
LAA 108 al. 1 let. a; OLAA 48; capacité de discernement et expertise médicale en assurance sociale: les frais d’expertise peuvent être mis à la charge de l’assureur lorsque l’instruction est insuffisante. L’incapacité totale de se comporter raisonnablement s’apprécie selon les critères du droit des assurances sociales et non par renvoi à l’irresponsabilité pénale de l’art. 10 CP. Lorsque l’expertise médicale est probante et ne souffre pas de contradictions déterminantes, l’assureur ne peut s’en écarter sans motifs sérieux. Le contrôle judiciaire porte sur la cohérence, la complétude et la force probante de l’avis expert, non sur une substitution libre de l’appréciation médicale.
Descripteurs
ASSURANCE SOCIALE; AM; FRAIS DE LA PROCEDURE; EXPERTISE; SUICIDE; ACCIDENT; AA; CAPACITE DE DISCERNEMENT; FAUTE; IRRESPONSABILITE
Normes
LAA.108 al.1 litt.a; OLAA.48
Résumé
Frais d'expertise mis à la charge de l'assurance dès lors qu'elle n'a pas suffisamment instruit la cause. L'incapacité totale de se comporter raisonnablement ne doit pas s'examiner en référence à l'irresponsabilité pénale selon l'art.10 CPS. Recourant jugé incapable d'agir raisonnablement selon une expertise médicale. La caisse ne pouvait s'écarter des conclusions de l'expertise.
Extraído pela Omnilex
Whether the expert opinion costs had to be charged to the insurer because the case was insufficiently investigated.
Yes. Since the insurer had not adequately investigated the matter, it had to bear the costs of the expertise.
The court held that the procedural shortcomings in the insurer's fact-finding justified allocating the expert costs to it.
Whether the insured person had to be assessed by reference to criminal irresponsibility under Art. 10 SCC when determining capacity to act reasonably.
No. Total incapacity to act reasonably is not to be examined using the criminal-law concept of irresponsibility.
The assessment follows the social-insurance medical and legal criteria applicable to the case, not the criminal-law standard of responsibility.
Whether the insurer could depart from the conclusions of the medical expertise finding total incapacity to act reasonably.
No. The insurer was not entitled to disregard the expert conclusions.
The expertise was decisive on the relevant medical question and there were no sufficient grounds to set it aside.
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