ATA/595/1995•Reduction of psychotherapy coverage under social insurance
ATA/595/1995Tribunal de Justiça / Câmara Administrativa24 de out. de 1995Partially Granted
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The court held that the health insurer was justified in reducing reimbursement for the appellant’s psychotherapy under LAMA.23. However, because the appellant’s daughter had committed suicide, the court granted a transitional period of one year during which one weekly session must still be covered. After that period, the therapy may be reduced to one hour every 15 days.
LAMA.23; reduction of the insured person’s psychotherapy expenses; the insurer may lower the scope of treatment where the therapeutic needs no longer justify the previous intensity and medical economy so requires. Exceptional personal circumstances may, however, warrant a temporary maintenance of the higher treatment frequency for a transitional period. In such a case, the court may balance the insured’s concrete distress against the insurer’s interest in economical treatment and authorize a staged reduction after a limited period.
Descripteurs
ASSURANCE SOCIALE; PSYCHOTHERAPIE; ECONOMIE DU TRAITEMENT; EXPERTISE
Normes
LAMA.23
Résumé
La caisse-maladie était en droit de réduire la prise en charge des séances de psychothérapie de la recourante. Il se justifie toutefois de permettre pendant un an encore à cette dernière de bénéficier d'une séance par semaine en raison du fait que sa fille s'est suicidée. Après cette période, les séances peuvent être réduite à 1 h. tous les 15 jours.
Extraído pela Omnilex
Whether the health insurer could reduce coverage for psychotherapy sessions.
The insurer was entitled to reduce the reimbursement of psychotherapy sessions.
The treatment economy and the medical assessment justified lowering the number of covered sessions.
Whether a transitional period with weekly psychotherapy should still be granted because of the daughter’s suicide.
A one-year transitional period with one weekly session was justified.
The particularly grave emotional impact of the daughter’s suicide warranted maintaining the higher frequency for a limited period before further reduction.
What level of psychotherapy should apply after the transitional period.
After one year, the sessions may be reduced to one hour every 15 days.
Once the transitional period expires, the reduced treatment schedule is sufficient.
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