Etcheverry, Roberto Eduardo v. Omint Sociedad Anónima y Servicios

E. 34. XXXV
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The Petitioner, Roberto Eduardo Etcheverry, worked for ISC Bunker Ramos S.A between April 1992 and June 1993, and was formally employed by them until 1997. During his employment, he was a member of Omint, a health insurance company. His coverage with Omint was paid for by ISC Bunker Ramos under an unwritten arrangement. ISC Bunker Ramos continued paying for his health insurance after July 1993 until the termination of his employment in August 1997, even though from 1993 to 1995 he provided services to them as an employee of another company and no real work relationship between Etcheverry and ISC Bunker Ramos persisted after July 1993.

Etcheverry found out that he was HIV-positive in January 1997. He underwent a series of tests that was paid for by ISC Bunker Ramos. Shortly after he received his test results, ISC Bunker Ramos formally terminated his employment with them. Subsequently, Etcheverry attempted to pay the fees required of an independent member of Omint. At that point, he was informed that his coverage had ended with his employment. Moreover, Omint refused to allow Etcheverrry to enrol as an independent member.

Etcheverry filed a guarantee of protection of individual constitutional rights (amparo protection) alleging a violation of the right to health. At issue in the case was whether the contract to provide prepaid medical services was formed between Omint and Etcheverry, or Omint and his employer. The lower court had ruled in favor of the latter. Etcheverry appealed.

The Supreme Court overturned the lower court's decision under Art. 16 of Law 48 and ordered the prepaid medical care provider to re-institute the prepaid medical services under the terms of the original contract signed by the Petitioner.

The majority of the Court did not provide their own analysis of the case, but rather, based their decision on the Attorney General's report. The Attorney General's report underscored that companies conducting prepaid medicine activities assumed the responsibility of protecting individuals' constitutional guarantees to life, health, security and integrity.  The Attorney General found that Omint had violated the contractual relationship formed between Petitioner and the prepaid medical care provider, and that it had also failed to protect the consumer under the Consumer Protection Law Nº 24240. Finally, the Attorney General underscored that prepaid medical care providers enjoy an important social role not enjoyed by other type of companies, and that such providers bear the responsibility of providing the necessary medical and psychological treatment and pharmaceuticals to persons living with HIV.

Dr. Don Adolfo Roberto Vasquez wrote a separate concurring opinion. In his opinion, it was not relevant whether coverage was arranged through ISC Bunker Ramos on behalf of Etcheverry, or Etcheverry himself contracted with Omint. In each case, the benefit accrued to Etcheverry. Given that Etcheverry was willing to pay for independent membership, the economic equation was unchanged when his employment was terminated. Further, the company had continued to pay for Etcheverry’s coverage even while he was an employee of another company, so there was no definitive proof that the contract was between the employer and Omint.

The Minister also considered that the purpose of insurance contracts was for persons like the Petitioner to be able to pay steady amounts over time to be protected from life or health risks into the future. To deny the Petitioner this protection even though he continued to pay would undermine the special relationship embodied in insurance contracts.

The Minister finally commented that Etcheverry, as a carrier of the HIV virus, would need special care for the rest of his life. He therefore considered that Omint’s decision to terminate his membership was intended to eliminate a business risk, an action he considered ‘reprehensible’ given that actuarial calculations had already accounted for such risks with sufficient certainty to make a profit for the provider.  The Minister commented that in this respect, the lower court had a duty to “[affirm] that values such as health and life cannot be measured by any economic criteria.”

This was especially so given that Etcheverry would not be able to arrange alternative coverage after contracting HIV, and would therefore be left entirely without protection. In this regard, the Minister emphasised that Omint had “completely ignored that one of its fundamental functions is the protection of health,” as well as its duties to interpret the relevant laws in favour of the consumer and to provide the same “required benefits” under the law as social welfare programmes, including to AIDS sufferers.

The Minister therefore agreed that the decision of the lower court should be vacated.

Minister Doctors Don Augusto Cesar Belluscio, Don Enrique Santiago Petracchi, and Don Gustavo A. Bossert dissented on the basis that the application was inadmissible under article 280 of the Federal Civil and Commercial Code of Procedure, but did not elaborate further.

Spanish - Attorney General Opinion:

Part IV: "Y es que no debe olvidarse que si bien a la actividad que asumen las empresas de medicina prepaga atañe esa índole (arts. 7 y 8, inc. 5°, del Cód. de Com.), en tanto ellas tienden a proteger las garantías constitucionales a la vida, salud, seguridad e integridad de las personas (v. arts. 3, "Declaración Universal de los Derechos Humanos"; 4 y 5 de la "Convención Americana sobre Derechos Humanos" y 42 y 75, inc. 22, de la Ley Fundamental), también adquieren un compromiso social con sus usuarios que obsta a que, sin más, puedan desconocer un contrato, so consecuencia de contrariar su propio objeto, que debe efectivamente asegurar a los beneficiarios las coberturas tanto pactadas como legalmente establecidas (v. art. 1°, ley 24.754)."

Part V: "[S]e añade que se trata la presente de una figura contractual "de adhesión" y "de consumo", puesto que amén de adherirse a las cláusulas predispuestas de una empresa, existe un servicio prestado para un destinatario final, siéndole aplicables, por ende, las disposiciones de la ley 24.240 (de Defensa del Consumidor) y la particular hermenéutica jurisprudencial y legal elaborada a propósito de esta materia. Ella ordena, respecto de la Ley de Defensa del Consumidor y demás leyes aplicables a las operaciones de consumo se esté, de entre todos los sentidos posibles, al que favorezca al consumidor, criterio que se extiende igualmente a los contratos (v. arts. 3 y 37 de la ley 24.240). […]El amparista, situado como consumidor en una posición de subordinación estructural y urgido ciertamente de tutela, acude por esta vía sumaria ante los tribunales de justicia postulando, en definitiva, que so pretexto de un argumento de autonomía contractual, la demandada le ha negado la cobertura médico - asistencial a la que se había comprometido."

Part VI: "Para concluir, previo puntualizar que atañe particularmente a las entidades de medicina prepaga la cobertura de los tratamientos médicos, psicológicos y farmacológicos de quienes padecen el síndrome de inmunodeficiencia adquirida (SIDA), en virtud de lo previsto por la ley 24.754, y que es en razón de su importante función social que resultan beneficiadas con la exención de pago de ciertos tributos, de lo que no gozan otras empresas comerciales cuyo objeto no tiene esta proyección social, destaco que el reclamante, tras revistar más de cinco años como beneficiario de la accionada y habiendo adquirido el virus del H.I.V., se ve impedido de contar con la asistencia médica intermediada por ésta, en virtud de las circunstancias de que se diera cuenta durante el desarrollo de este dictamen."

 

Spanish - English, Concurring Opinion of Don Adolfo Roberto Vazquez:

“Que, sentado lo expuesto, surge con nitidez que las notas características de estos contratos de adhesión estuvieron presentes en la relación de que tratan las presentes actuaciones, dado que independientemente de quien pagara la cobertura médica prometida al actor, lo real y concreto fue que se le aseguró la atención médica para cuando ocurriese una eventualidad, enmarcándose el vínculo con elementos de previsión tendientes a la búsqueda de la seguridad y midiéndose la correspectividad de las prestaciones en un lapso prolongado.” Paragraph 10

“That, given the above-expressed, it becomes clear that the characteristic qualities of these adhesion contracts were present in the relationship in this case, given that independent of who paid the medical coverage promised to the plaintiff, the reality is that he obtained medical insurance for when a health problem might occur, which created a relationship based on advance consideration of a need for security and the possibility of medical care during a prolonged lapse.” Paragraph 10

 

"Que, por otro lado, si se repara en que el amparista por ser portador del virus HIV requerirá atención médica especial de por vida, puede extraerse que la negativa de la prepaga obedeció a su intención de liberarse del riesgo empresario. Este intento de la accionada de incumplir deliberadamente una obligación contraída, resulta reprochable desde todo punto de vista, máxime si se tiene en cuenta que en este tipo de empresas se realizan cálculos actuariales que permiten establecer -con bastante certeza- los riesgos como el aquí considerado y así calcular la cuota a cargo del beneficiario con un margen apreciable de ganancia para la prestadora médica." Paragraph 12

“On the other hand, if the plaintiff by being a people living with HIV will need medical attention for the rest of his life, it can be concluded that the refusal of the respondent to provide health care was the result of its intention of release from business risk. This intent of the company to deliberately violate its contractual obligation is reprehensible in every aspect, particularly if one keeps in mind that in this type of company actuarial calculations are made that permit the establishment – with sufficient certainty – of the risks like those in this case and thus can calculate the payment to be made by the beneficiary with an appreciable profit for the medical provider.” Paragraph 12

 

"Que a lo dicho se suma, todavía, la circunstancia de que el rechazo del actor implicó su total desprotección, puesto que, en los hechos, resulta imposible pensar que tiene posibilidades de acceder a una institución similar encontrándose ya instalada en él una enfermedad como el SIDA.
En este aspecto, cabe hacer hincapié en que la conceptualización del derecho como justicia y equidad imponía al tribunal a quo la necesidad de afirmar que valores tales como la salud y la vida están por encima de todo criterio económico." Paragraph 13

“The refusal of the plaintiff’s healthcare implied a complete lack of protection because it is impossible for him to access a similar health insurance company given he lives with HIV.

We should highlight that the law should be interpreted as justice and equity and the lower court should have incorporated values such as the right to health and the right to life which are above any economic criteria.” Paragraph 13

 

"En este punto, es importante poner de resalto que la citada ley representa un instrumento al que recurre el Estado a fin de equilibrar la medicina y la economía, puesto que se tienen en consideración los delicados intereses en juego -integridad psicofísica, salud y vida de las personas así como también que más allá de su constitución como empresas los entes de medicina prepaga tiene a su cargo una trascendental función social que está por encima de toda cuestión comercial." Paragraph 15

“Regarding this point, it is important to emphasize that the cited law [24,754] represents an instrument to which the State resorts to balance medicine and economics, given that it must consider the delicate interests in play – a person’s psychophysical integrity, health and life – as well as the fact that beyond their mere incorporation as companies, the prepaid medicine entities have a vital social function that is above and beyond any economic matter.” Paragraph 15

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