projetos

Good-faith reimbursement of a no-longer-covered medicine

ATA/85/1996Tribunal de Justiça / Câmara Administrativa13 de fev. de 1996

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Extraído pela Omnilex

Resumo Omnilex

The case concerned a medicine that had ceased to be obligatorily reimbursed under health insurance. The court held that a convention between insurers and pharmacists requiring notice to customers did not bind insured persons, since they were not parties to it. If the insurer itself did not inform its insureds, it must bear the consequences of a pharmacist’s failure to warn when the insured could in good faith assume that coverage continued.

Sumário Omnilex

LAMA art. 12 para. 2 ch. 1 lit. c; reimbursement of a medicine no longer compulsorily covered by health insurance; the convention between insurers and pharmacists requiring information to customers does not bind insureds, who are not parties to it. Where the insurer has not informed its insureds and the insured could in good faith assume continued coverage, the insurer must bear the consequences of the lack of information and reimburse the costs, notwithstanding the pharmacist’s omission.

Texto completo

Descripteurs

ASSURANCE SOCIALE; AM; MEDICAMENT; PRINCIPE DE LA BONNE FOI; REMBOURSEMENT DE FRAIS(ASSURANCE); ASSU

Normes

LAMA.12 al.2 ch.1 litt.c

Résumé

Cas d'un médicament qui cesse d'être obligatoirement remboursé par les caisses-maladie. La convention liant les caisses et les pharmaciens, selon laquelle ces derniers doivent rendre leurs clients attentifs au fait que tels médicaments ne sont plus pris en charge par l'assurance, ne lie pas les assurés qui n'y sont pas partie. Par conséquent, il incombe à la caisse qui n'a pas informé ses assurés d'assumer la responsabilité d'un remboursement en cas de défaut d'information de la part du pharmacien, si l'assuré pouvait de bonne foi penser que le médicament en cause continuait à être pris en charge.

Palavras-chave

social insurancehealth insurancemedicinereimbursementgood faithduty to informpharmacistinsured person

Extraído pela Omnilex

Questões jurídicas principais extraídas pela Omnilex

Questão jurídica principal

Whether a health insurer must reimburse a medicine that is no longer mandatorily covered when the insured was not informed of the change.

Decisão extraída

The insurer may have to bear the reimbursement risk if it failed to inform its insureds and the insured could in good faith believe the medicine was still covered.

Fundamentação extraída

The convention between insurers and pharmacists, requiring pharmacists to alert customers that certain medicines are no longer covered, does not bind insured persons who are not party to it. If the insurer did not itself inform its insureds, it must bear the consequences of a lack of information communicated by the pharmacist when the insured acted in good faith.

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