Enforceability of the settlement against third-party payers
Facts and procedure :
1. According to the judgment under appeal (Versailles, 30 April 2020), from 1995 to 1999, Mediator was prescribed to [M] [N] who, in 1999, developed pulmonary arterial hypertension requiring a lung transplant.
2. After requesting a legal expertiseM] [N] has, with relatives (the [N] consorts) :
- sued Les laboratoires Servier and Les laboratoires Servier industrie; producer of Mediator (the companies),
- and implicated the Caisse primaire d'assurance maladie des Hauts-de-Seine (the Caisse), which sought reimbursement of his out-of-pocket expenses.
3. Following the death of [M] [N] on 13 January 2015, the [N] consorts entered into a settlement with the companies and withdrew their action.
Proceedings continued between the caisse and the companies.
Examination of the pleas in law (Enforceability of the settlement against third-party payers) :
The second plea
Statement of the case
" (...) 4. The fund complains that the judgment dismissed its claims on the grounds that 'the fund is subrogated, by operation of law, to the rights of the victim ;
that the fund may require the liable third party to reimburse the benefits paid to the victim if the liable third party has reached a settlement with the victim without calling on the fund to participate;
in this case, the health insurance fund does not have to justify the liability of the third party; nor can the third party invoke against the fund any exonerations of liability that it has not invoked against the victim;
in considering that the fund could rely on the exemption from liability that the third party had not invoked against the victim during the settlement concluded with the latter in the absence of the fund,
the Court of Appeal therefore violated Articles L. 376-1 to L. 376-4 of the Social Security Code1382 now 1240and 1386-11 became 1245-19 of the Civil Code. ".
Court's reply (Enforceability of the settlement against third-party payers) :
Having regard to Articles L. 376-1, L. 376-3 and L. 376-4 of the Social Security Code and the article 2044 of the Civil Code :
5. According to the first three of these texts, the social security funds have a subrogatory right of recourse against third parties in respect of compensation for losses for which they have assumed responsibility; if an out-of-court settlement has been reached between the third party and the insured person, the fund cannot be held liable if it has not been invited to take part; the fund must be informed of this and, in the absence of such information, the limitation period cannot be invoked against it and a penalty is paid to it on the occasion of its subrogatory right of recourse.
6. According to the last of these texts, a transaction is a contract by which the parties, by mutual concessions, put an end to a dispute that has arisen or prevent a dispute from arising.
7. A third party to a contract may invoke in his favour, as constituting a legal fact, the situation created by this contract; 2nd Civil Court, 10 November 2021, Appeal no. 19-24.696, published.
8. It follows that, where a person enters into an agreement with the victim of a personal injury or his successors in title a settlement relating to compensation for the resulting damage; it therefore admits, in principle, a the victim's right to compensation which the fund, subrogated to its rights, may invoke.
9. It is then up to the trial courts, hearing the subrogation action brought by the fund, which has not been invited to take part in the settlement, to order the parties to produce the settlement in order to ascertain its content and, where appropriate, to determine the sums owed to the fund, by assessing the victim's losses, specifying which items of loss have been covered by the benefits paid and making the corresponding allocations.
10. In rejecting the fund's claims, the judgment held that :
– the latter cannot validly maintain that the transaction concluded between the rights holders and the companies,
– with which the Court of Appeal is unfamiliar and the terms of which it is unaware,
– would be sufficient to substantiate its claim and that Article L. 376-4 of the Social Security Code does not prohibit companies from invoking the benefit of the exemption from liability provided for in Article 1386-11 of the Social Security Code. ; now 1245-19, of the French Civil Code.
11. In so ruling, the Court of Appeal violated the aforementioned provisions.
FOR THESE REASONS, and without it being necessary to rule on the first plea, the Court :
REVERSE AND ANNUL, except in so far as :
- that it uphold the judgment dismissing the claims of Les laboratoires Servier industrie and Les laboratoires Servier
- their request to revoke the closing order
- and the Caisse primaire d'assurance maladie des Hauts-de-Seine (Hauts-de-Seine health insurance fund) of its request that the proceedings be referred back to the juge de la mise en état,
- the judgment of the Versailles Court of Appeal of 30 April 2020;
Remits the case and the parties, except as regards these points, to the status they were in before this judgment; refers them back to the Versailles Court of Appeal otherwise composed;
Orders Les laboratoires Servier industrie and Les laboratoires Servier to pay the costs;
Pursuant to Article 700 of the Code of Civil Procedure:
- dismisses the claim brought by Les laboratoires Servier industrie and Les laboratoires Servier,
- and therefore orders them to pay the Caisse primaire d'assurance maladie des Hauts-de-Seine the total sum of EUR 3,000 (...)'.
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