The Supreme Court (TS) has ruled in favor of a man who underwent emergency surgery for severe septicemia in the United States and who was demanding that his insurer reimburse him for almost 30,000 euros of medical expenses, something to which the company He refused for not notifying in time.
In a sentence, to which Europa Press has had access, the Civil Chamber of the TS partially accepts the man's appeal, confirming the sentence handed down in 2017 by the Court of First Instance Number 38 of Barcelona, which condemned the insurer to pay the invoice of 31,586.31 dollars up to the limit of 30,000 euros established by the contracted insurance.
The facts date back to November 15, 2015, when the man, while traveling in Boston, “had to be admitted to the Massachusetts General Hospital (MGH) for presenting a serious septic condition, where he remained until the 19th of November. November when he was discharged, to continue treatment in Spain”.
Months later, on April 25, 2016, the MHG informed the patient that he had to pay him $31,586.31, which he “immediately claimed” from his insurer.. This, however, refused to pay because “the incident had not been communicated to it”.
Given the insurer's refusal, the man filed a claim in the aforementioned court of first instance, which agreed with him, although the company appealed and the Barcelona Court supported his thesis, so the insured went to the Supreme Court, which aligns with the first of the sentences.
The insurer claimed, first of all, that “there was no insurance contract between the parties”, but that it simply “offered its partners, due to their status as such, a series of benefits”, including “coverage up to 30,000 euros for 'medical, surgical, pharmaceutical and hospitalization expenses abroad'”.
Likewise, it argued that “the plaintiff failed to meet the requirements to benefit from the benefit, since he did not notify the alarm center” in advance and, “in the event that an insurance relationship was recognized, that the plaintiff did not respect the deadline either of seven days for the communication of the sinister”.
“Contracts are what they are”
The Supreme begins by establishing that “it is settled jurisprudence that contracts are what they are and not what the parties call”.
Thus, it indicates that, “if we find that an insurance company from the same group” of which the man was a member “committed to cover the expenses of medical assistance abroad, up to a quantitative limit, and the document spoke of expressly covering benefits and communication and occurrence of the accident, it is clear that this legal relationship fits the definition of insurance contract”.
Moreover, the First Chamber emphasizes that “the defendant's own acts reveal the existence of an insurance relationship, since upon receiving the first communication” from the man “he did not deny the existence of insurance, but rather denied the benefit for an alleged exclusion of coverage, for not having made the communication in the following 24 hours”.
From there, the Supreme Court resolved that “the initial delay in reporting the claim was justified by the seriousness of the insured's state of health, who had to undergo emergency surgery to treat sepsis”.
“While the subsequent delay (not concealment of information) there is no evidence that it caused economic damages to the insurer, or at least, nor have they been justified by it, nor has it claimed them by way of counterclaim or compensation,” he concludes..