A question of law. A maternal assistant from the Jura was on sick leave for seven months after an accident at work, a rupture of the partial ligament of an inch. Authorized to go out without time restrictions by her doctor, she went several times with her dogs to an educator. But the activity is “unauthorized”, according to Health Insurance, which claims more than 9,000 euros in compensation paid, reveal our colleagues from Progress.
Arrested in October 2021 at first without authorization to leave, her doctor first granted her “authorized exits” (the stop sheets indicate that the insured must be present at her home between 9 a.m. and 11 a.m. and between 2 p.m. and 4 p.m. ) then without time restrictions for the following shutdown extensions.
La Jurassienne regularly takes her dogs to a trainer. But one day, “Health Insurance called me to tell me that they had been on the site of the place of training and that it was an unauthorized activity”, she declares to Progress.
Result: Health Insurance claims reimbursement of 9,367 euros, or all of the benefits received.
Health insurance is in its right
The childminder must then resume work on May 2, but she is again arrested on July 20. “I had no improvements after having surgery. Health insurance called me back to tell me that I was lying, that I was working, ”she continues.
Health Insurance is in its right, under Article L323-6 of the Social Security Code, which stipulates that daily allowances are not due in the event of non-compliance by the insured.
Asked by ProgressMe Corinne Leclerc, lawyer at the Onelow firm in Lyon, specifies that “outings authorized without time restrictions does not mean that one is completely “free””. Outings authorized without time restrictions are only “by exception, for duly justified medical reasons”.
Since April 2021, in order to avoid stops of convenience, the doctor must specify the medical elements motivating these outings. And that even involves bringing or picking up your children at school.
Similar cases have been brought to court. For the most part, the CPAM has been judged in its right by the Court of Cassation.
In short, when a person is arrested, he must ensure that the doctor indicates all the reasons for leaving.