projetos

Mandatory health insurance cancellation requires proof of affiliation

ATA/418/1997Tribunal de Justiça / Câmara Administrativa1 de jul. de 1997Partially Granted

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Extraído pela Omnilex

Resumo Omnilex

The court held that the former health insurer could not rely on a cancellation of compulsory basic insurance because it had never received proof that the appellant had joined another insurer for mandatory coverage. By contrast, the resignation from complementary insurance was valid. The appellant’s argument that her declaration was vitiated by cortisone treatment and limited knowledge of French was rejected. The decision thus distinguished between mandatory health insurance and supplementary coverage, applying the civil-law rules on defects of consent in an administrative context.

Sumário Omnilex

Art. 7 al. 5, 12 and 102 LAMal; cancellation of compulsory health insurance and proof of affiliation; validity of termination of supplementary insurance and defects of consent. The termination of mandatory health insurance is ineffective unless the former insurer receives an affiliation certificate establishing coverage by another insurer for the compulsory benefits. This requirement does not extend to supplementary insurance, whose termination is assessed separately under the contractual rules. A declaration of cancellation may be challenged for defect of consent, but the burden lies on the party invoking it to substantiate the alleged impairment; civil-code principles on consent defects apply by analogy in administrative insurance disputes.

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; AFFILIATION; ASSURANCE OBLIGATOIRE; RESILIATION; ASSURANCE COMPLEMENTAIRE; CONDITIONS GENERALES DU CONTRAT; COUVERTURE; ASSUREUR-MALADIE; DOUBLE ASSURANCE

Normes

LAMAL.7 al.5; LAMAL.12; LAMAL.102

Résumé

L'ancienne assurance-maladie de la recourante ne peut se prévaloir d'une résiliation, dès lors qu'elle n'a jamais reçu d'attestation d'affiliation d'une autre assurance pour les prestations obligatoires des soins. Il n'en va pas de même de la démission portant sur les assurances complémentaires de la recourante. Rejet du grief invoquant un vice du consentement consécutif à la prise de forte doses de cortisone et à une méconnaissance du français. Application des dispositions du CO en droit administratif. L'ancienne assurance-maladie de la recourante ne peut se prévaloir d'une résiliation, dès lors qu'elle n'a jamais reçu d'attestation d'affiliation d'une autre assurance pour les prestations obligatoires des soins. Il n'en va pas de même de la démission portant sur les assurances complémentaires de la recourante. Rejet du grief invoquant un vice du consentement consécutif à la prise de forte doses de cortisone et à une méconnaissance du français. Application des dispositions du CO en droit administratif. L'ancienne assurance-maladie de la recourante ne peut se prévaloir d'une résiliation, dès lors qu'elle n'a jamais reçu d'attestation d'affiliation d'une autre assurance pour les prestations obligatoires des soins. Il n'en va pas de même de la démission portant sur les assurances complémentaires de la recourante. Rejet du grief invoquant un vice du consentement consécutif à la prise de forte doses de cortisone et à une méconnaissance du français. Application des dispositions du CO en droit administratif.

Palavras-chave

social insurancehealth insuranceaffiliationmandatory coveragecancellationsupplementary insurancecontract conditionsconsent defectdouble insurance

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether the cancellation of mandatory health insurance was effective without proof of affiliation to another insurer for compulsory benefits.

Decisão extraída

The insurer could not rely on a termination of the mandatory insurance because it never received an affiliation certificate from another insurer for compulsory care coverage.

Fundamentação extraída

Under the applicable health insurance rules, termination of compulsory coverage presupposes evidence that the insured has joined another insurer for the mandatory benefits; absent that proof, the former insurer remains bound.

Questão jurídica principal

Whether the resignation from complementary insurance policies was valid.

Decisão extraída

The resignation of the complementary insurance contracts was effective.

Fundamentação extraída

The court distinguished complementary coverage from compulsory health insurance and accepted the termination for the supplementary policies.

Questão jurídica principal

Whether the appellant could invalidate the cancellation by invoking a defect of consent due to high-dose cortisone and lack of French-language knowledge.

Decisão extraída

The alleged defect of consent was rejected.

Fundamentação extraída

The court found no sufficient basis to set aside the declaration of cancellation on the grounds invoked by the appellant.

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