Overview:
In its ruling SC3075-2024, dated December 19, 2024, the Supreme Court of Justice (“SCJ”) addressed a dispute between a medical clinic and an insurer concerning the denial of indemnity claims under the Mandatory Traffic Accident Insurance (“SOAT”).
Key facts:
Between 2017 and 2019, the clinic provided medical treatment to victims of traffic accidents involving vehicles allegedly insured under SOAT policies issued by the defendant insurer. The clinic submitted indemnity claims in line with regulatory guidelines, but these were rejected by the insurer on grounds of alleged fraud by the policyholders, including staged accidents or misuse of the policies. In response, the clinic initiated legal proceedings to recover the unpaid amounts.
Key Findings by the SCJ:
1. Right of healthcare providers:
Healthcare providers are entitled to seek reimbursement from SOAT insurers for medical services rendered to accident victims. Evidence required includes proof of the accident and its consequences, such as certification of occurrence of the accident or certification of treatment of the bodily injuries, as specified under Article 194 of the Financial Statute.
2. Statute of Limitations:
The SCJ reaffirmed that claims under SOAT are subject to a two-year statute of limitations. This period begins on the date the victim received medical treatment or was discharged, as stipulated in Article 1081 of the Colombian Commercial Code and Decree 780 of 2016.
3. Insurer’s Defenses:
Insurers cannot rely on allegations of bad faith by policyholders (e.g., staged accidents or policy misuse) to deny claims from healthcare providers unless they can demonstrate that the provider acted maliciously. The SCJ highlighted that it is the insurer’s responsibility to audit claims and substantiate any allegations of fraud or irregularities on the part of the policyholder.
Significance:
This ruling reinforces the protections afforded to healthcare providers under SOAT regulations. It clarifies evidentiary requirements, the applicable statute of limitations, and the scope of insurers’ defenses. The decision strikes a balance between the right of insurers to conduct audits and their obligation to honor legitimate claims.
Lucas Fajardo Gutiérrez.
Luis Alejandro Peña.
Insuralex Colombia, Brigard Urrutia
