Facts
The case concerns an insured person, Y., who worked for the administration of the city of Z. until February 28, 1997, and was insured by insurance company X. through a group insurance policy. After the end of his employment contract, he became unemployed and was transferred to the individual insurance of the same insurance company on March 1, 1997. The individual insurance offered a daily allowance of 70 Swiss francs from the 31st day for a period of 720 days, similar to the group insurance.
Y. was unable to work due to alcohol abuse from November 18, 1997, to February 27, 1998, and from May 21 to August 8, 1999. He applied for daily allowances to insurance company X., which refused, citing a general exclusion for alcoholism in the general terms and conditions of the individual insurance.
Y. brought an action against X. before the administrative court of the canton of Thurgau, which granted his request. Insurance company X. appealed to the Federal Court.
Considerations
The Federal Court examined the concept of reserve within the meaning of Article 71 paragraph 1 of the Federal Act on Health Insurance (HIA). It considered that this provision aims to ensure the maintenance of insurance benefits for persons who leave a group insurance to join an individual insurance.
The court analyzed the general terms and conditions of the group insurance and the individual insurance. It found that the terms of the individual insurance contained a general exclusion for alcoholism, unlike the terms of the group insurance.
The Federal…