ATA/502/1997•Vertebral fracture and accident-equivalent injury under insurance law
ATA/502/1997Tribunal de Justiça / Câmara Administrativa26 de ago. de 1997
Extraído pela Omnilex
The case concerns social insurance coverage for an alleged vertebral fracture. The decisive question was whether the fracture was medically established and, if so, whether it had to be treated as an accident-equivalent bodily injury under Art. 9 para. 2 lit. a OLAA. The fracture was denied on the evidence, so no coverage could be derived from the provision on accident-equivalent injuries.
Art. 9 para. 2 lit. a OLAA; accident-equivalent bodily injury; proof of vertebral fracture. Coverage as an accident-equivalent injury presupposes that the alleged bodily lesion is established on the evidence. If the existence of the fracture is not proven, the claim fails without further examination of the accident-equivalent qualification. The insurer is therefore not liable where the medical findings do not sufficiently demonstrate a vertebral fracture (cf. consid. not specified).
Descripteurs
ASSURANCE SOCIALE; ACCIDENT; AA; FRACTURE; LESION CORPORELLE ASSIMILEE A UN ACCIDENT; ASSU
Normes
OLAA.9 al.2 litt.a
Résumé
Question de l'existence d'une fracture vertébrale - niée en l'espèce - et de sa prise en charge éventuelle au titre de lésion assimilée à un accident.
Extraído pela Omnilex
Whether a vertebral fracture was established on the facts.
The existence of a vertebral fracture was denied.
The medical and factual record did not sufficiently establish that such a fracture had occurred.
Whether the alleged vertebral fracture qualified for coverage as an accident-equivalent bodily injury under Art. 9 para. 2 lit. a OLAA.
Coverage as an accident-equivalent injury was not granted because the fracture itself was not established.
Without proof of the fracture, there was no basis to apply the rule on accident-equivalent bodily injuries.
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