Court orders worker to be reimbursed 26,000 euros in treatment expenses after insurance company's medical care proves to be 'absolutely useless'
The employee underwent 11 operations and received more than 550 physiotherapy and psychiatric sessions that didn't resolve the problem, until he went down the private healthcare route
After suffering an accident at work on 26 September 2011, a company employee in Spain was diagnosed with a severe open fracture of the right elbow that became infected and caused damage to the ulnar and radial nerves.
His employer provided him with treatment through the mutual insurance company Fraternidad Muprespa, which collaborates with the national Social Security system. He underwent 11 operations and received more than 550 physiotherapy and psychiatric sessions. All of these were paid for by Fraternidad Muprespa.
However, as his state worsened, in 2019, he asked to be operated on by a highly renowned surgeon in the private health sector (Clínica Vithas in Valencia), whose methods had a 90% success rate. Fraternidad Muprespa refused him and proposed a procedure which, according to the insurer, "entailed fewer risks and was more realistic in terms of success".
Reimbursement refusal
Faced with uncertainty and denial, the employee went to a private clinic and paid for two successful operations out of his own pocket. He then decided to claim reimbursement from the mutual insurance company and the Social Security authorities. The total cost he had covered amounted to 25,811.43 euros.
After many years of disagreements and, finally, litigation, in May this year, the High Court of Justice of Madrid ruled justified the worker's request for reimbursement, considering the "ineffectiveness" of the treatment offered by the mutual insurance company.
In the ruling, the judges stated that they could not ignore "the enormous and long-lasting complications" and the "absolutely useless" assistance provided by Fraternidad Muprespa. It has been considered proven that the worker's state continued worsening, putting his physical and emotional well-being at stake, despite the prolonged treatment funded by the insurer.
As his improvement after he took matters in his own hands has shown, the private treatment was decisive in reversing his deterioration. According to the court, the latest couple of surgeries could even lead to a review of the declaration of absolute permanent disability, which was judicially recognised on 15 December 2016.
The ruling states that the patient's health "remained critical, with practically no chance of improvement" despite the insurer's proposed treatment. Therefore, the worker's search for "the most qualified and accurate healthcare" was "not only logical" but also successful.
