By ruling SC3075-2024 dated December 19, 2024, the Civil, Agricultural, and Rural Chamber of the Supreme Court of Justice (hereinafter, the “SCJ”) resolved a dispute between (i) a medical clinic that provided healthcare services covered under the Mandatory Traffic Accident Insurance (“SOAT” by its acronym in Spanish) to individuals injured in traffic accidents, and (ii) the insurer that issued the policies.
Facts:
Between July 2017 and September 2019, the clinic treated several individuals injured in traffic accidents involving vehicles allegedly insured under a SOAT policy issued by the defendant insurer.
The clinic submitted claims to the insurer for indemnification in accordance with the guidelines established in Decree 56 of 2015. However, the insurer rejected the claims, alleging that the patients had filed fraudulent claims, as they had either “faked a traffic accident to receive medical care” or “used insurance policies that did not correspond to the vehicles involved in the incident.” Faced with the rejection of the claims, the clinic filed a lawsuit before the civil jurisdiction to recover compensation.
Procedural History:
The 16th Civil Court of the Circuit of Barranquilla denied the claims, noting that 247 of the 400 submitted claims were time-barred. Regarding the remaining claims, the court stated that the clinic failed to meet the burden of proof to demonstrate that the hospital bills pertained to incidents arising from traffic accidents involving vehicles covered by a SOAT policy issued by the defendant insurer.
The clinic appealed, but the appellate court upheld the lower court’s decision, concluding that: (i) claims arising from SOAT must be submitted within the timeframe established by Article 1081 of the Commercial Code; (ii) the ordinary statute of limitations under the cited article begins to run from the date the claim is submitted to the insurer; and (iii) the clinic failed to meet the burden of proving that the accident involved a vehicle covered under a SOAT policy.
The plaintiff filed a cassation appeal against the appellate court's decision. The SCJ partially overturned the ruling and ordered payment for the 132 claims that had not expired, including their respective default interest, based on the following:
Considerations:
- Right of healthcare providers to claim indemnification:
The SCJ emphasized that healthcare providers have the right to claim compensation from the SOAT insurers for expenses incurred in treating victims of traffic accidents involving a vehicle covered under such policies. To file a valid claim, it suffices to meet evidentiary requirements under Article 194 of the Organic Statute of the Financial System (“EOSF” by its acronym in Spanish) and its regulatory framework.
“Additionally, Article 194 of the EOSF provides that for the coverage of medical expenses under SOAT:
All indemnity payments shall be made upon demonstration of the accident and its harmful consequences for the victim. The following shall be considered sufficient evidence, in addition to any other evidence the victim or their legal successor may provide, as applicable to the type of coverage:
a. Certification of the occurrence of the accident. The National Government will regulate the means of proving the occurrence. Certification issued by the physician who initially treated the emergency at the hospital shall be considered proof.
b. Certification of treatment for bodily injuries or permanent disability caused by traffic accidents, issued by any duly authorized medical, care, or hospital entity (...).”
- Statute of limitations for claims:
The SCJ clarified that the statute of limitations applicable to claims arising from the SOAT is established in Article 1081 of the Commercial Code, in accordance with the express provisions of Article 2.6.1.4.4.1 of Decree 780 of 2016.
Furthermore, the aforementioned decree specifies that the limitation period begins to run from the moment the victim received medical attention or was discharged from the health care provider. The CSJ further clarified that this limitation period applies equally to both declaratory and executive actions.
"In summary, the ordinary statute of limitations for enforcement and declaratory actions available to healthcare providers (IPS) to claim payment under the health expense coverage of the SOAT is two years, counted from the moment the IPS 'became aware or should have become aware of the fact that gives rise to the action,' which, according to specialized regulations, occurs when the accident victim 'was treated or (...) was discharged from the healthcare institution.'"
- Insurer’s defenses:
The SCJ ruled that allegations of bad faith by policyholders, such as using “borrowed SOAT’s” or staging accidents, cannot be raised against the health care provided that treated the victims to deny the claims. The insurer bears the responsibility to audit the supporting documentation and prove the policyholders’ bad faith.
“In other words, absent any malicious conduct by the treating IPS—which was not alleged in this case—a fraudulent act, as described by the insurer in its defense, could only occur if the policyholder presented themselves at the medical center and, through deceit, led the treating professionals to believe their injuries resulted from a traffic accident, knowing otherwise, or if the policyholder knowingly allowed a third party to use their policy, violating the law. In both cases, breaching their contractual duties.
Thus, the breaches of good faith obligations cited in the aforementioned defense can only be attributed to the SOAT policyholders and cannot justify withholding payments owed to the IPS.”
(…)
“Conversely, the Court considers it reasonable for IPS to independently prepare all documents comprising a proper claim, while it is equally valid for insurers to conduct a thorough audit.
(…)
Such insurer oversight may yield various results, including: (i) confirming the validity of the claim, enabling payment; (ii) identifying formal deficiencies, which, as explained, may be addressed through administrative objections; or (iii) detecting substantive irregularities, such as nonpayment, expiration, setoff, or fraudulent circumstances”.
If you wish to review ruling SC3075-2024 dated December 19, 2024, click here.