Facts
The 1955-born V. suffered an accident insured under AIA with the Swiss National Insurance Company (hereinafter: National) on February 27, 1994. On September 13, 2001, V. took his own life. By letter of January 28, 2002, the heirs of V. asserted a claim for survivor's benefits from National. The insurer denied its liability after a brief exchange of letters by letter of May 8, 2002.
On June 14, 2005, the heirs of V. renewed their application for payment of survivor's benefits. National stated in a letter of August 4, 2005, that it considered the case closed, as the notification of May 8, 2002, had become final as a de facto decision.
The heirs of V. filed a complaint for denial of justice on September 12, 2006. The Social Insurance Court of the Canton of Zurich upheld it and obliged National to issue a written and reasoned decision with information on legal remedies regarding survivor's benefits.
Considerations
The Federal Court had to decide whether National committed a denial of justice by rejecting a decision after the expiry of the one-year period since the informal procedure was improperly used to communicate the closure of the case.
The court stated that National rejected the claim for survivor's benefits by letter of May 8, 2002, without issuing a formal decision. This letter was not designated as a decision and did not contain information on legal remedies. The court therefore qualified the letter as an informal disposition and not as a formal decision.
The court decided that National was obliged to issue a formal decision, as it concerned a significant benefit for which the law prescribes the decision form. The informal disposition was therefore inadmissible.
The court stated that the insured person must contact the accident insurer within one year of the informal procedure being improperly used to…