Breast or facial corrective surgery not aesthetic if medically necessary

ATA/390/1997Tribunal de Justiça / Câmara Administrativa24 de jun. de 1997Granted

Extraído pela Omnilex

Resumo Omnilex

The case concerned whether interventions intended to correct difficult mobilization of the chin muscles were excluded as cosmetic surgery under the old health insurance statute. The court held that the procedures were not aesthetic operations because their purpose was not merely to change the claimant's appearance, but to alleviate a persistent physical disorder. Coverage therefore had to be granted under Art. 12 al. 2 ch. 2 LAMA.

Sumário Omnilex

Art. 12 al. 2 ch. 2 LAMA; distinction between aesthetic surgery and medically indicated treatment. Interventions are not excluded as cosmetic operations when, according to their objective and therapeutic function, they are intended to remedy a lasting physical impairment and not merely to modify the patient's physiognomy. The qualifying criterion is the medical purpose of the procedure; an appearance-related benefit alone is insufficient, whereas treatment of a persistent functional disorder brings the intervention within insured medical care.

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; ASSURANCE COMPLEMENTAIRE; COUVERTURE; SOINS MEDICAUX; FRAIS(EN GENERAL); LIMITATION; THERAPIE; OPERATION; TRAITEMENT(EN GENERAL); PRESTATION D'ASSURANCE(EN GENERAL); OPERATION DE CHIRURGIE COSMETIQUE; ASSU

Normes

LAMA.12 al.2 ch.2

Résumé

Des interventions médicales destinées à corriger une mobilisation difficile des muscles du menton ne peuvent être qualifiées d'opérations esthétiques, leur but n'étant pas simplement de modifier la physionomie de la recourante, mais de la soulager d'un trouble physique persistant.

Palavras-chave

social insurancehealth insurancemedical treatmentcoveragecosmetic surgerytherapeutic necessitymedical expensesfunctional impairment

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether the disputed interventions are cosmetic surgery excluded from coverage or medically necessary treatment covered by social insurance.

Decisão extraída

The interventions are not aesthetic operations; their purpose is not merely to alter appearance but to relieve a persistent physical disorder.

Fundamentação extraída

The decisive criterion is the therapeutic aim and functional necessity of the intervention. Where the procedure addresses an ongoing physical impairment, it cannot be classified as a purely cosmetic operation.

Breast or facial corrective surgery not aesthetic if medically necessaryGerado por IA