Facts
[B.] was affiliated with Assura health and accident insurance when he was the victim of an accident at the X recreation center on November 20, 1999. Assura covered the treatment costs without deducting the deductible and cost-sharing from the insured. Subsequently, Assura approached the liability insurer of the recreation center operator to obtain reimbursement of its benefits. A settlement was reached on the basis of shared liability at 50%. Assura then asked [B.] to reimburse the balance of the deductible and cost-sharing that it had not been able to recover from the liability insurer.
[B.] contested this request before the Cantonal Tribunal of the Republic and Canton of Jura, which upheld his appeal. Assura then filed an administrative law appeal against this judgment with the Federal Tribunal.
Considerations
According to case law, the legal subrogation provided for in Art. 79 HIA does not apply to the deductible and cost-sharing of treatment costs, which constitute an uncovered amount that can be the subject of a direct action by the injured party against the liable third party. The health insurer is therefore not entitled to recover them from the liable third party, nor to claim them from the insured.
Although the practice of certain health insurers is to reimburse the full amount of medical costs and then include the insured's participation in the costs in their action against the liable third party, this practice is not in accordance with the law.
In the present case, Assura acted legally in…