Judgment No. 2063
1. THE EPO SHALL PAY THE COMPLAINANT 3,000 EUROS IN MORAL DAMAGES.
2. IT SHALL PAY HIM 3,000 EUROS IN COSTS.
3. HIS OTHER CLAIMS ARE DISMISSED.
"The Tribunal is fully competent to consider whether the Office is right in maintaining that [the insurance broker] Van Breda correctly exercised its authority in rejecting the request to meet the cost of transferring the complainant to a convalescent home."
complaint allowed; complaint allowed in part; competence of tribunal; insurance; refund; judicial review; discretion; refusal; request by a party
"The authority of the insurance brokers goes beyond a simple right to make an administrative check of the claims it receives [...]. [Insurers] have the right to check whether, under the insurance contract, they are liable for the costs of the care dispensed. But they must so exercise that authority as to provide the insured with a guarantee that their claims to coverage are examined with all due care."
complaint allowed; complaint allowed in part; contract; insurance; insurance benefit; refund; discretion; condition; request by a party; safeguard; duty of care
After the complainant underwent surgery, the insurance brokers refused to cover his convalescence in a home. "In order to assess any physical injury suffered by the complainant, it is necessary to ascertain the later consequences for his health of the refusal to meet the costs of his admission to a convalescent home, and the fact that he did not as a result stay in such a home. These are purely medical matters which [...] need to be referred to the Invalidity Committee".
claim; complaint allowed; complaint allowed in part; receivability of the complaint; competence; illness; insurance benefit; medical board; refund; consequence; refusal; request by a party