INS and CCSS Liability for Medical Abandonment After Exhaustion of SOA PolicyResponsabilidad del INS y la CCSS por desamparo médico tras agotamiento de póliza SOA

“VII.- On the partial merits of the claim. This Tribunal considers that it must partially uphold this claim as it was brought against both defendants and based on the following considerations:

1.- On the system of non-contractual civil liability of the public administration. Whenever we find ourselves dealing with the parties in litigation in determining potential pecuniary liability of the Public Administration, if the legal relationship that binds the citizen to the sued administration does not arise from the existence of a contractual instrument, then the discussion revolves around what is known as non-contractual civil liability, which is why it is necessary, by way of introduction for the purposes of this instrument, to refer to the elements that, in doctrine and jurisprudence, render a claim of liability, such as the one sought here, feasible. Within the system of so-called non-contractual civil liability, two types are distinguished: subjective liability, established in Article 1045 of the Civil Code, and objective liability, regulated in Section 9 of the Political Constitution, Article 1048 of the Civil Code, and Section 190 et seq. of the General Law of Public Administration. Regarding the system of subjective liability, Article 199 of the General Law of Public Administration establishes the liability of public servants to third parties in cases of proven intent (dolo) or gross negligence (culpa grave) in the performance of their duties or on the occasion of their fulfillment. As such, subjective liability is based exclusively on an examination of whether the agent's state of mind included at least “negligence,” if not “intent,” unlike what occurs with the objective liability system, under which liability is determined independently of the existence of such subjective elements. Under subjective liability, one is liable because one is culpable, either because the production of the damage was sought or desired, or because one acted imprudently or negligently. In observance of the foregoing, a public servant's liability to third parties falls within the scope of the subjective liability system; consequently, for all purposes of determining the existence of negligence or intent in the state of mind of the servant or agent of the Administration, without prejudice to the other elements that must concur—such as the existence of the damage and the causal link between it and the conduct displayed—the finding of liability will apply. On the other hand, the system of objective liability of the Public Administration, unlike what occurs with subjective liability, is generated without the need to prove the intent or negligence of the agent causing the damage, requiring instead, of course, proof of the existence of the “risk” to generate it, which is why the notions of unlawfulness and culpability do not apply; therefore, the principle of reversal of the burden of proof for the benefit of the injured party applies. For these purposes, the alleged Public Administration causing the claimed damages must compensate for them if its conduct effectively and efficiently generated them, unless it proves an exonerating cause, without prejudice to the fact that, as an unavoidable condition, the harmful effect must indeed constitute the cause of the deployment of its activity. Thus, the concurrence of four elements is required, namely: a) An injury, consisting of unlawful pecuniary damages, because the one who suffers them does not have the duty to bear them; b) An administrative conduct with which the production of the alleged damage is linked; c) A causal link, formed by the existence of a direct cause-and-effect relationship between the act (administrative conduct) attributed and the damage produced; and d) The absence of the justifying causes to which we referred above, since their existence can legally disconnect the damage produced from the conduct of the Public Administration, such that the harmful effect is not attributable to it, breaking the causal link upon the occurrence of an exonerating situation such as force majeure, the fault of the victim, and the act of a third party. The system of patrimonial liability of the State and its institutions, provided for in Articles 9 and 41 of the Political Constitution and 190 et seq. of the General Law of Public Administration, is, therefore, essentially objective in nature, so that for it to arise, it is sufficient that there exists an indemnifiable damage, an administrative conduct, and a causal link between them. It must be understood that it is under this type of objective criterion that it is possible to attribute liability to the Public Administration, unlike what occurs with its servants, for whom a subjective attribution criterion must also be used. Moreover, having determined the criteria under which it is appropriate to establish the liability of the Public Administration and/or its agents or public servants, we are interested in pointing out that, at the same time, there is a difference regarding the imputation criteria that apply to the establishment or determination of such liability when dealing with lawful or unlawful, normal or abnormal, activity of the Administration. Quoting Dr. Ernesto Jinesta Lobo, from his work Tratado de Derecho Administrativo II, Responsabilidad Administrativa, p. 39, it is stated: “In the system of liability without fault or for special sacrifice, liability for lawful conduct or normal functioning, the determining criterion for the existence of liability on the part of public administrations is the breach of the principle of equality in the bearing of public burdens and the consequent special damage (small proportion of affected persons) and abnormal damage (intense exceptionality of the injury), or the risk theory for the hypothesis of accidental damages caused by a public administration in the fulfillment of the function assigned by the legal system. In the case of the system of liability for lack of service—unlawful conduct or abnormal functioning—the imputation criterion is constituted, precisely, by that indeterminate legal concept of ‘lack of service’ and the unnamed or atypical constitutional right of citizens to be provided with efficient and effective public services.” In liability for unlawful or abnormal conduct, understood as conduct that opposes, infringes, or violates the legal system, considered globally as written and unwritten norms, the burden of proof corresponds to the victim, who bears the duty to demonstrate, through the forms and evidentiary means that the legal system permits, the lack of service, its abnormal functioning, or the unlawfulness of the administrative action. In liability for lawful conduct, it has been established that even conduct deployed in compliance with the legal system is susceptible to attributing liability to the Administration under criteria such as those mentioned supra. In cases of objective liability, the Administration's defense would lie in demonstrating that one of the causes breaking the causal link, as indicated in Section 190, paragraph 1 of the General Law of Public Administration, has intervened, whether, as indicated supra, force majeure, the act of a third party, or an act of the victim himself. Our First Chamber of the Supreme Court of Justice, in Resolution No. 000584-F-2005, at 10:40 a.m. on August 11, 2005, stated, and always in relation to objective liability, the following: "...there shall be liability on the part of the Administration whenever its normal or abnormal functioning causes damage that the victim does not have the duty to bear, whether patrimonial or non-patrimonial, independently of his subjective legal situation and the title or power condition that he holds, provided, of course, that the indispensable prerequisite of the causal link is met. (...) Both the essential prerequisites and the burden of proof acquire, for example, a new nuance, which frees the affected party not only from substantial constraints but also procedural ones, and places the Administration in the obligated discharge against the charges and facts attributed to it. In any case, the objective character of the non-contractual civil liability of the Administration was clearly defined in the judgment of this Chamber No. 132 at 3:00 p.m. on August 14, 1991, for an event subsequent to the entry into force of the General Law of Public Administration, in which it stated: "VI. Our General Law of Public Administration No. 6227 (...), as indicated by the judgment of this Chamber No. 81 of 1984, in resolving the controversy over its enforceability, in Title Seven of Book One, embodied the most modern principles, founded on the most authoritative doctrine and jurisprudence, regarding the non-contractual liability of the Administration, thus establishing the direct liability of the State without the need to prove beforehand that the damage was produced by the fault of the official or of the Administration, requiring, for the admissibility of compensation, that the damage suffered be effective, assessable, and individualizable in relation to a person or group —Article 196—. (...) It also establishes, in an exhaustive manner, the exonerating causes for said liability: force majeure, fault of the victim, and the act of a third party, with the burden on the Administration to prove their existence, (...)" (The highlighting is not from the original). In particular, regarding the potential liability of an entity such as the Caja Costarricense del Seguro Social associated with the provision of health services that are under its charge, the First Chamber of the Court, in its Decision No. 7 at 2:20 p.m. on January 13, 1995, has also indicated as follows: "(...) It is this theory of objective liability that requires that the risk created cause compensable damage to the citizen, (...). V)- To restore the liability of the Caja Costarricense de Seguro Social, the causal link must be recognized between the damage caused to the plaintiff and the action of said entity, i.e., between the act challenged and the harmful event. (...) The causal relationship between the act (the activity consisting of providing medical services) and the effect (...) is clear, unavoidable, and strictly attributable to the sued institution. It is not necessary to object that the patient was or was not hypersensitive to the prescribed medication, but only—as the expert affirmed ( ...)— that a risk was created which, as an exception to the common resistance of organisms—caused damage to the patient, and he has no reason to bear it without—at least—being compensated for it. In summary, the risk was created by the Caja Costarricense de Seguro Social, through its hospitals, causing damage to the patient, now plaintiff, and, consequently, based on the aforementioned risk theory, it must be held liable for its action. (The highlighting is not from the original). Consequently and in accordance with all of the foregoing, the determination of the existence of the claimed damage would be fruitless if, once identified by the plaintiff, the alleged administrative conduct—in this case, the performance of medical procedures that do not result in an adequate and timely diagnosis of the ailment the patient suffers—is not proven, because, from the outset, it would not even be possible to determine that, linked to the medical service provided to the plaintiff, a causal link intervened to allow the conclusion that it was this procedure, and not another circumstance, that objectively and effectively constituted the genesis or origin of the alleged damage.- 2.- On the right to health and access to medical services. The right to health constitutes a fundamental right enshrined in the Political Constitution, as its Sections 21 and 50 (right to life and to a healthy and ecologically balanced environment) are interrelated. From this, and to a large extent, its effective guarantee comes from a service-provision function, because it is the health services provided by hospital centers, among others, that are directly aimed at addressing the health conditions of the general population. Consequently, the State or its institutions—among which is the Caja Costarricense del Seguro Social and, to a different degree, the Instituto Nacional de Seguros in what corresponds to it according to the law—are mandated to adopt all necessary and positive measures or actions to guarantee that right in an adequate and reasonable manner. It is not superfluous to indicate that both institutions, among others—public and private—form part of what has been called the Sistema Nacional de Salud according to the respective regulation, Articles 1 to 4, 9, 18, and 82, which was published in the Official Gazette “La Gaceta” No. 230 of December 5, 1989, Executive Decree No. 19276-S of 11/09/1989. On the other hand, there are the deontological rules governing the exercise of the arts associated with health and medical science, as well as those aimed at the regulation of hospital centers themselves—both public and private. The Sala Constitucional has been responsible for the dimensioning of this right and thus, in its judgment No. 2010-07602 at 2:49 p.m. on April 27, 2010, stated in this regard: “The World Health Organization (WHO) in its Constitution—adopted in New York in 1946—defined health as the state of complete physical, mental, spiritual, emotional, and social well-being, and not merely the absence of afflictions or diseases. Regarding the right to health, in a broad sense, the following provision of this Tribunal in Decision No. 1915-92 at 2:12 p.m. on July 22, 1992, is illustrative, and, in relevant part, states: '(...) the right to health has the fundamental purpose of making the right to life effective, because the latter does not protect only the biological existence of the person, but also the other aspects derived from it. It is rightly said that the human being is the only being in nature with teleological conduct, because he lives according to his ideas, purposes, and spiritual aspirations. In this condition of being a cultural being lies the explanation for the necessary protection that, in a civilized world, must be granted to his right to life in all its extension, consequently to a healthy life. If among the extensions that this right has is, as explained, the right to health or health care, this includes the State's duty to guarantee the prevention and treatment of illnesses (...).' Equally categorical is the provision of this Chamber in Judgment No. 11222-03 at 5:48 p.m. on September 30, 2003, when stating the following: '(...) VI.- FUNDAMENTAL RIGHT TO HEALTH. The right to life recognized in Section 21 of the Constitution is the cornerstone upon which the rest of the fundamental rights of the inhabitants of the republic rest. Similarly, in that ordinal of the political charter, the right to health finds its foundation, since life is inconceivable if the human person is not guaranteed minimum conditions for an adequate and harmonious psychic, physical, and environmental balance (...).' In this way, it must be re-emphasized that the stated fundamental right is guaranteed through actions aimed at preserving human life under minimum conditions that foster an integral, adequate, and harmonious psychic, physical, and environmental balance, all of which, of course, is directly applicable to the operation of hospitals, as well as the practice of medical science, among other activities and sciences, as well as diverse professions that, in their exercise, affect this topic. Moreover, the right to health is recognized at the level of international law: Article 25 of the Universal Declaration of Human Rights; 7 and 1 of the American Declaration, 3, 6, 23, and 24 of the Convention on the Rights of the Child. Consequently, and without losing sight of the fact that the legal operator must observe the principle of conventionality control, both constitutional law and any instrument of international law that protects a right of this kind more robustly than the former shall inform the interpretation and application of infra-constitutional normative order in the solution of problems in specific cases. Being our interest the topic related to the provision of medical services, see also what was stated by the Sala Constitucional in its judgment No. 2011-003683 at 3:47 p.m. on March 22, 2011, in which the following was stated: “It suffices only to consult the International Covenant on Economic, Social and Cultural Rights, in its Section 12, to realize what we have been affirming. Indeed, in said international human rights instrument, the right of every person to enjoy the highest attainable standard of physical and mental health is clearly established, whereby the State and its institutions have the duty to ensure the full effectiveness of that right through a series of positive actions and the exercise of regulatory, oversight, and health police powers. The foregoing means, no more and no less, the prevention and effective treatment of diseases, as well as the creation of conditions that ensure medical assistance and quality medical services for all in case of illness. Having said that, the right to health includes the availability of health services and programs in sufficient quantity for users of these services and beneficiaries of these programs. Moreover, the right to health also entails accessibility to these services and programs, whose four dimensions are non-discrimination in access to health services, physical accessibility—particularly for the most vulnerable—, economic accessibility—which entails equity and the affordability of health goods and services—, and accessibility to information. No less important is that health services and programs be acceptable, i.e., respectful of medical ethics, culturally appropriate, aimed at improving patients' health, confidential, etc. Finally, and no less relevant for that reason, the right to health implies quality services and programs, which means that such services must be scientifically and medically appropriate.” Now, taking into account the foregoing, we will proceed to the analysis of the merits or lack thereof of the claims sought in the present lawsuit, under the terms of this instrument.- 3.- On the mandatory insurance for motor vehicles. We consider it opportune, as it is concise yet comprehensive, to cite what was stated in this regard by Section VIII of this Tribunal in its judgment 110 - 2013 at 3:00 p.m. on November 28, 2013, an occasion on which the following was noted on this topic: “IV.- (...) The so-called Mandatory Automobile Insurance corresponds to an instrument of protection and economic support (concretized contractually between the owner of a vehicle and a public or private insurer) for the potential victims of a traffic accident, which is imposed by the legal system on vehicle owners as an authorization requirement for their movement within the national territory. Through it, drivers, passengers, and third parties—pedestrians or travelers—are covered in relation to the risk generated by the activity of driving a motor vehicle, which may potentially cause the death of citizens, or their total or partial disability, as well as medical, hospital, and rehabilitation expenses, travel allowances, food, or other circumstances—according to the parameters of the insurance—covered through subsidies, in the event of a traffic accident. It certainly has an implicit public interest which, it must be clarified, does not imply a transmutation of said mechanism into a social security, since the duty to acquire it is linked and directed to the ownership of a vehicle and, consequently, whoever takes it out will establish a private contractual link with the insurance entity that provides the service. In this line, it must be emphasized that the limit of the quantum of the subsidies that may eventually be granted is subject, on the one hand, to the type and degree of the injuries caused and, on the other hand, to the sum agreed upon between the private insured party and the insurance company, which is generally defined in an adhesion clause of the contract, which varies from time to time. Simultaneously, this insurance entails an element of protection of the patrimony of the vehicle owner (or its driver) responsible for the injury, who may suddenly face financial tension upon the unforeseen causation of an injury, such that the SOA also functions as a means of compensation or balance of the patrimony of the party causing the damage, even though, eventually, that liability may exceed the agreed coverage, in which case, once the insurance amount is satisfied, the insurance entity dissociates itself from the matter, leaving the generator of the detriment directly obligated by constitutional imperative (Section 41 of the Political Constitution), which was already indirectly addressed in regard to mandatory insurance by the First Chamber of the Supreme Court of Justice through Decision No. 30-F-2005 at 10:45 a.m. on January 27, 2005. From a regulatory perspective, the SOA originates in the Traffic Law, namely, No. 5322 of August 27, 1973, repealed by Law No. 5930 of September 13, 1976, which in turn was replaced by the Law on Transit on Public Land Roads, No. 7331 of April 13, 1993, and its subsequent reforms. On the date when the accident giving rise to this proceeding occurred, the insurance amount was set at three million colones, and Law No. 8696 of December 17, 2008, was applicable, as well as the Regulation on Mandatory Insurance for Motor Vehicles No. 25.370-MOPT-J-MP of July 4, 1996. In general, we proceed to refer to the legal bases of importance for this type of insurance. Thus, Section 39 of the Law establishes the mandatory nature of said instrument, while providing the basis for the issuance of regulatory rule-making. Section 49 expressly states: "The mandatory vehicle insurance covers injury and death of persons, victims of a traffic accident, whether or not there is subjective liability of the driver. It also covers accidents caused with civil liability, arising from the possession, use, or maintenance of the vehicle. In this latter case, this liability must be determined through established procedures and before competent courts." For their part, Sections 52 and 53 define the limits and applicable economic benefits, and Section 51 indicates that the maximum coverage limit of the mandatory vehicle insurance will be defined by the regulation to the Law, which is determined by Article 14 ...”. (The highlighting is not from the original). It must be noted that the Instituto Nacional de Seguros, in what concerns its administration of this insurance and, at the same time, its direct provision of health services through its hospital center, exercises functions that are bifurcated in terms of their regulation, the first being of a commercial nature under an ordinary and principal economic activity—today liberalized within the framework of the insurance market—and, on the other hand, a service-provision function regarding the provision of hospital services, which, associated or not with the coverage of an insurance policy, corresponds to activity governed by special regulations, thus informed by the rules of the arts associated with medical science and, in this latter respect, by the deontological rules that govern medical action through the professionals in that area through whom a nosocomio acts.- 4.- On the nature of the services provided by the Instituto Nacional de Seguros. Although this topic appears to be undisputed, due to its relevance for the issuance of this ruling, it must be revisited. A special regulatory body in the matter first implemented can be located starting from October 2, 1922, with the Insurance Law No. 11, published in the corresponding Colección de Leyes y Decretos for that year, second semester, first volume, page 314, at a time when the activity related to the possibility of commercially accepting, in exchange for the payment of a premium, the transfer of risks to which third parties are exposed, if they are insurable, so that in case of the occurrence of a foreseeable circumstance justifying it, an indemnification becomes dispensable to cover the economic burden that such event may generate due to the harmful effects on the insured party's patrimony and/or personal integrity, was liberalized to free competition. On October 30, 1924, Law No. 12 of that date, today, the Law of the Instituto Nacional de Seguros, was enacted, by which the previous Insurance Law was entirely repealed. An entity was created through it under the name Banco Nacional de Seguros, which would later mutate into an institute. The creation of this organization occurred pursuant to Sections 4 and 5 of said law, providing from then on for the future monopolization of the market, while being designed for the Banco Nacional de Seguros to contract and execute State insurance. Later, in Article 5 of this regulatory body, the Instituto Nacional de Seguros was created based on the reform implemented by Law No. 4183 of September 4, 1968, which, related to the subsequent reform implemented by Law No. 6082 of August 30, 1977, and Law 6082 of the same year, ultimately established the State monopoly, which meant that this activity was exclusively under the administration of said institute, operating as an autonomous entity. At present, the Law of the Instituto Nacional de Seguros is in force pursuant to the text of its constitutive law, as reformed in accordance with Article 52 of the Law Regulating the Insurance Market, No. 8653 of July 22, 2008, published in the Official Gazette “La Gaceta” No. 152, Supplement 3, of August 7 of the same year. This reform came as a consequence of the obligations acquired by the State with its counterparts in the relevant context, on the occasion of the adoption of the Free Trade Agreement, United States, Central America, and the Dominican Republic, approved by Law No. 8622 of November 21, 2007, published in the Official Gazette “La Gaceta” No. 246, of December 21 of that same year, Supplement 40. The resulting commitments of interest are located within the annex of the treaty corresponding to financial services and in insurance matters. (See constitutional Article 7).

Thus, the first article of the Law of the National Insurance Institute, amended by the Insurance Market Regulatory Law, provided as follows in relevant part: "The National Insurance Institute, hereinafter INS, is the autonomous insurance institution of the State, with its own legal personality and patrimony, authorized to carry out insurance and reinsurance activity. In such activities, the regulation, supervision, and sanctioning regime established for all insurance entities shall apply to it. / (...). / In carrying out insurance activity in the country, which includes the administration of commercial insurance, the administration of Occupational Hazard Insurance and Mandatory Automobile Insurance, the INS shall have the full guarantee of the State. / The INS is empowered to establish or acquire equity interests in corporations, commercial companies, branches, agencies, or any other commercial entity of a similar nature, none of which shall enjoy the guarantee indicated in the preceding paragraph, for the following purposes: a) To exercise the activities entrusted to it by law within the country. Such activities include those of a financial nature, the granting of credit, the provision of health services and those specific to the Fire Department, the provision of medical benefits, and the sale of goods acquired by the INS by reason of its activities. / In addition, the INS may establish, by itself or through its companies, strategic alliances with public or private entities in the country or abroad, for the sole purpose of fulfilling its competence. / Both the INS and its corporations, with the approval of their respective boards of directors, may incur debt prudently in accordance with the corresponding financial studies. These operations shall not have the guarantee of the State. / Public banks are authorized to participate as shareholders of the corporations that the INS establishes as indicated in this article, provided that the INS remains the majority shareholder of said companies." The text, as indicated, corresponds to the historical moment in which, as a result of the scope of the aforementioned free trade agreement, the existing monopoly was broken and the insurance market was completely opened, in all its forms, to free competition for products associated with insurance. From the outset, the first article indicated corresponds to a legislative line powerfully oriented toward reinforcing the Institute's capacity to act under the private law regime, so that, its activity being of public interest, it is directed toward successful participation in the free market of products associated with insurance activity, as part of the state productive sector. The core or epicentral activity of the Institute, according to its founding law, is the commercialization of insurance products; however, other activities have also been such, like associated financial activities, and another activity unrelated to this specific main commercial activity within the framework of a liberalized market, which is preserved residually—one might say—as a product of those moments when the activity was under the state monopoly by its means, such as the activity deployed by the Fire Department, which, before the reform occasioned by the same Insurance Market Regulatory Law, was established as an organ with minimal deconcentration. Today, it is an organ with instrumental legal personality and maximum deconcentration, attached to the Institute according to Law of the Meritorious Fire Department No. 8338 of March 19, 2002, Articles 1 and 2. On the other hand, there are the activities linked to medical benefits, which are originated in a direct link with insurance activity, so that these are medical services provided through its own hospital centers or through third parties with whom it associates for that purpose, which in both cases correspond to a private-type service subject to the existence of an insurance contract, marketable by any authorized insurer, different from those that would have to be understood as being included within the social security services administered by the Caja Costarricense del Seguro Social, the latter being those regarding which their nature as a service universally open to the public can indeed be affirmed. These medical services provided by the Institute, as could be done by any authorized third party, it is insisted, clearly correspond to the effects and scope of the services associated as a benefit to some of its products, such as so-called personal insurance. The constituent advanced something of this, based on the content given to Article 73 of the Magna Carta, when determining a special regime to be developed by the ordinary legislator, and different from that corresponding to social insurance, for the case of mandatory occupational hazard insurance, established with the purpose of protecting workers with the cost borne by their employer, serving as a mechanism for access to health services. It is an insurance that operates as an exclusive obligation of employers toward the workers with whom they are linked, that is, charged exclusively to their patrimony and as determined by the corresponding regulations. On account of this, the employer must mandatorily acquire, within the market, the corresponding insurance product in order to comply with this provision, just as it is mandatory for owners of motor vehicles to pay, in order to access the right of circulation, the corresponding mandatory insurance, which would essentially cover death and/or the care of injuries caused by a traffic accident. Currently, the Insurance Market Regulatory Law, which as an effect of the Free Trade Agreement noted above fostered the opening of the market to such a degree that both mandatory automobile vehicle insurance and occupational hazard insurance were included under the terms of Transitory Provision III of that law, related to its Article 2, last paragraph, with only the mandatory social security systems administered by the Caja Costarricense de Seguro Social and the special pension regimes created by law and the mandatory mutual policy administered by the Sociedad de Seguros de Vida del Magisterio Nacional being exempted from the application of this regulation and, therefore, outside free commerce, indicates that the services provided by the Institute in health matters are not services of a social nature with the openness of those provided by the Caja Costarricense del Seguro Social. This liberalization could be noted as acceptable according to Constitutional law, since the Sala Constitucional in its judgment number 2001-12952, of sixteen hours twenty-four minutes on December eighteenth, two thousand one, affirmed as follows: "II.- The second and third points of the inquiry are intimately linked, insofar as they start from the premise that the National Insurance Institute has constitutionally assigned competence in matters of occupational hazards, which is inaccurate. Constitutional Article 73 clearly states that 'Insurance against occupational hazards shall be exclusively at the expense of employers and shall be governed by special provisions,' from which it is concluded that it is the law that is responsible for developing them. Constitutional Article 188 merely indicates that the insurers of the State are autonomous institutions, and from that provision it cannot be validly concluded that the Constitution has granted the INS exclusive competence in matters of occupational hazards. Occupational hazard insurance, as a monopoly of the State, has its origin in Law No. 12 of the month of October 1924; by Law No. 33 of December 23, 1936, the National Insurance Institute was born into legal life, to which the competence was maintained to commercialize, among other types of insurance, the occupational hazards insurance that concerns us. Subsequently, Constitutional Article 73 established occupational hazard insurance 'at the expense of employers,' leaving the regulation to ordinary law, which has not undergone any modification, and therefore the National Insurance Institute has maintained that competence over the years. The reading of the Minutes of the National Constituent Assembly clearly shows us that Article 73 was drafted in a broad manner to allow, in the future, for matters related to disability, old age, death, and occupational hazard insurance to be in a single direction; consequently, the establishment of logical collaboration between State institutions cannot be considered contrary to the constitutional order, for which it is not necessary to comply with the hearing procedure that the inquirers miss." (Highlighting is not from the original). Well then, the legislator took account of this type of autonomous organizations, such as the defendant Institute, when enacting the Ley General de la Administración Pública number 6227 in nineteen seventy-eight. According to its Articles 1 to 3, the Public Administration, through its various organic manifestations, has the capacity under both public and private law to act, and then, with public law being what governs the activity of the State, although it also applies to other public entities other than the State, such as decentralized ones, it is so provided that there is no law to the contrary. Therefore, it is possible for private law to regulate a specific activity of those entities when a law so indicates, which may well occur because, due to their overall regime and the requirements of their line of business, they must be considered as common industrial or commercial enterprises. The foregoing is reinforced if one observes the content of Articles 111 and 112 of the same legal body regarding what regulates service relationships between the Administration and its agents, when the latter do not participate in what can be understood as public management, or who participate in a legal relationship with public enterprises or economic services of the State responsible for activities subject to common law. By the finalist principle of interpretation of the norms and without prejudice to ideological positions that in the past and present may nuance what will be said differently, from its existence once the Ley General de la Administración Pública was enacted, and later, with the foregoing reinforced and qualified from the entry into force of the Securities Market Regulatory Law, the latter informed by the scope of the Free Trade Agreement between the United States, Central America, and the Dominican Republic, approved by Law number 8622, it is clear that the legal nature of the National Insurance Institute is that of a state public enterprise, created under the form of Public Law, nevertheless created for the provision of commercial services regulated by common law. The organization is located within the framework of what is understood within the productive sector of the decentralized public institutional organization. One must observe Article 2 of the Law of the National Insurance Institute in what it indicates as follows: "Application of Private Law. The acts generated from the development of its commercial insurance activity, acting as a common commercial enterprise, shall be regulated by Private Law, so that in the exercise of insurance activity, the Institute shall be subject to the jurisdiction of the ordinary courts." As a derivation from the above, given the activity that this entity legally carries out, none of its manifestations is or constitutes a public service, since they do not share its characteristics with it, except for the one associated with fire extinguishing, residing in a legal-person organ that is attached to it, such as the Fire Department, without this particular activity constituting the neuralgic axis of the entity. It must be noted that even including the commercialization of mandatory automobile insurance or occupational hazard insurance within the Institute's activity, however much social interest they may have, they are personal insurance products in the insurance market that today can be offered by any authorized participant, so they do not bear any difference from the rest of the products associated with this insurance market, becoming goods and services of a commercial nature in all their aspects. This affirmation is reinforced in the framework of a market liberalization to free competition in insurance matters, within which the legislator has also opted for reinforcing the capacity of this institution to deploy its capacity to act governed by private law, in order to ensure its successful participation in a framework of equality in the market, against other participants therein, which has been powerfully projected in its capacity not only to administer the management of its attributions and competences but also to self-organize for those purposes. The fact that the patrimony that the Institute administers constitutes part of the assets of the public treasury says nothing that does not operate for the rest of the state public enterprises that, like this one, exercise a commercial activity subject to private law, but at the same time, subject to certain controls that for each institution may vary in degree and intensity. (Articles 8 and 9 of the Organic Law of the Contraloría General de la República). Well then, it being necessary to take note, as we indicated above, that whether or not associated with the application of a policy within the framework of commercial-type insurance activity, the conduct deployed against the plaintiff by both the National Insurance Institute and the Caja Costarricense del Seguro Social proved misaligned with the legal system, so that in terms of benefits they did constitute, yes, at different levels, abnormal conducts that make the claim partly acceptable as will be seen, since they serve as a criterion for attributing patrimonial liability, given that they also constituted the origin of a moral harm intensely experienced by the plaintiff, which must.- 5.- On the partial success of the claim against the Caja Costarricense del Seguro Social. This Tribunal considers it appropriate to begin this section related to what, according to the facts that have been deemed proven, is relevant for the resolution of the point in question.

5.1.- In relation to this part, it is established that on March 8, 2012, Mr. Gilberto Badilla Castro suffered a traffic accident, as a result of which he presented injuries that warranted his transfer to a hospital, in this case, to the Hospital San Juan de Dios. (Uncontroverted fact, in relation to folio 108 of the clinical file of Hospital San Juan de Dios, in its Volume I, and folio 120 of the clinical file of the INS, in its Volume I, as well as folios 65 and 36 of the INS evidence bundle, as well as folio 10 of the precautionary measure bundle, and folios 85, 86, and 78 of the main file). In that hospital, the plaintiff was attended, given primary care, and stabilized, to then be referred to the INS, exclusively because it was institutionally known that he was covered by a policy of mandatory automobile vehicle insurance. (Uncontroverted fact, in relation to the testimony given in the supplementary hearing by Dr. Javier Francisco Soto Fallas). As a separate point, whether that was appropriate or not, it was an uncontroverted fact, which is also supported by the evidence at folio 75 of the file of the bundle identified as INS evidence. Well then, the plaintiff was indeed protected by a policy of this kind, but it would have corresponded to a discretion on his part to remain in that medical center in order to receive medical attention—Hospital San Juan de Dios—or to be transferred, as the case may be, to the INS, given that the application of the mentioned policy not only corresponds to a right that belongs exclusively to him and is waivable, but also because at the moment he suffered the traffic accident, he was insured by his employer directly as a salaried worker before the CCSS. (Uncontroverted fact, in relation to folio 11 of the precautionary measure bundle in which a copy of the employer order valid for the month the accident occurred is found, as well as folio 79 of the main file in which a copy of the card accrediting him as a direct insured is found). Without prejudice to it being clear that whether insured by the INS or not, the plaintiff was simultaneously insured by the CCSS, on this point, the provisions of Article 23 of the Regulation on Mandatory Automobile Vehicle Insurance are consistent, which reads as follows in the relevant part: "The health benefits established by this insurance shall begin to be provided by the doctors of the National Insurance Institute or those designated by it, or, the victim may contract them in their condition as injured party, but in this latter case, the cost of the health benefits that said Institute will recognize shall be subject, in order, to the current rates for similar services provided by the Institute, or failing that, those of the Caja Costarricense de Seguro Social, and lastly, those defined in agreements entered into between the Institute and private parties, without prejudice to the professional or the victims, if applicable, being able to collect the difference from the person responsible for the accident." That is to say, that the person insured by the INS in any case retains the right to choose by whom to be treated, which does not exclude the application of their policy, so that it could not be affirmed under the non-legal principle that whoever can do the more can do the less, that they could not choose to be attended by the CCSS, whether under the mandatory automobile vehicle insurance, or simply because they are an insured before said institution providing health services. In this line of thought, note that Dr. Javier Francisco Soto Fallas, a specialist at Hospital San Juan de Dios, informed in court that when a patient enters with injuries caused by a traffic accident, what is usually done with them is that they are asked if they are covered by a mandatory automobile vehicle insurance policy or not, so that if they say yes, they are referred to the INS, apparently automatically. It must be added that no evidence exists in the administrative files that the plaintiff was informed of his rights in this respect, nor that his referral to the INS corresponded with his will, although this aspect is not central for the resolution of the present matter insofar as it is also not recorded or has not been said on his part that action was taken against his will. Well then, having been referred to the INS by the medical authorities of the Hospital San Juan de Dios, the plaintiff entered that state enterprise (INS Salud) on March 9, 2012, where he was admitted and care was provided to him. On March 12, 2012, he was assessed in the orthopedics service by Dr. Max Rojas Badilla, (a witness in the present case who, having been admitted as evidence, the representation of the INS withdrew from at the oral hearing) who reportedly diagnosed the presence of a transcervical fracture of the neck of the left femur of the left hip, requiring surgery, for which, in a first order of ideas, removal of an element associated with previous osteosynthesis existing in the femur had to be performed, with both operations needing to be performed at the same time. (This is visible at folios 85 and 86 of the main file). Already at the INS, on March 17, 2012, and as part of the service provided to the plaintiff, he was transferred to Hospital La Católica where that surgical intervention was performed by the same Dr. Max Rojas Carranza. This, besides being an uncontroverted fact, is found at folios 39 and 40 of the INS evidence bundle. Two days later, on March 19, 2012, the plaintiff had been transferred back to the INS, where it was reported by its medical staff that due to his obesity, a better reduction was not possible, with a risk of necrosis or pseudoarthrosis of the hip. (This is extracted from the review of folio 12 of the main file, in relation to folios 84 and 109 of the precautionary measure bundle, and the testimony in the supplementary hearing by Dr. Javier Francisco Soto Fallas, who explained the surgical procedure performed in court). Later, by March 21, 2012, the plaintiff had been transferred by the medical authorities of the INS to his home. (Uncontroverted fact given the statements of the INS representation in its brief responding to the claim). By March 27, 2012, the coverage amount of the mandatory automobile vehicle insurance policy under which Mr. Gilberto Badilla Castro was being treated at the INS was already exhausted, as evidenced in the proof at folio 15 of the precautionary measure bundle, and would later explain the conduct adopted by that state enterprise. Prior to that, on April 9, 2012, the plaintiff had gone to the INS, where, because Dr. Max Rojas Carranza was not present, he was attended by Dr. Javier Castro Figuls, who noted that the hip presented three screws with some "varo," that is, "curvature," diagnosed that in the surgery performed there was damage to the hip, proceeded to remove the "avión," which is the device used to prevent rotation of the hip that had been placed after the surgery, and scheduled an appointment for the following April 23, and finally, he was sent home again. (This is a fact that is taken as proven since it did not prove to be controverted given the statements of the INS representation in the brief responding to the claim, as, outlined in the statement of claim, it was not rejected in that respect). The plaintiff had been scheduled for an appointment that should be understood to have been for follow-up; however, prior to that, on April 12, 2012, he presented himself again at the INS, where Dr. Max Rojas Carranza—who had treated him previously—limited himself to reviewing the insurance policy under which care was provided to him, proceeded to issue a discharge summary, and proceeded to transfer the plaintiff to the Caja Costarricense del Seguro Social because the coverage amount of that policy had been exhausted—which we stated had occurred on March 27, 2012—with the indication in the referral that it was to the orthopedics service and on an urgent basis. (This fact constituted one over which there was no controversy, as it was not rejected by the representation of the INS in its brief responding to the claim, and it is also supported by folio 189 of the INS clinical file, which contains the corresponding medical notes report). That was the state of affairs on April 17, 2012, the same day that, having been indicated to the plaintiff that he would no longer be treated at the INS due to what was stated, he was received at Hospital San Juan de Dios according to the indicated medical referral, where he was assessed by Dr. Daniel Martínez Castrido, who indicated that there had been a failure in one of the procedures performed, specifically the osteosynthesis, presenting migrated screws, displaced femoral head and neck, and that this corresponded to a complication of the surgery performed by the INS doctor, so that, considering that this circumstance excluded the responsibility for care from the Caja Costarricense del Seguro Social, the patient had to be given a counter-referral to the INS. Thus, he was discharged from Hospital San Juan de Dios that same day, April 17, 2012, the aforementioned failure in the procedure carried out at the INS consisting of the bone and/or its fragments not being properly aligned for the consolidation of the fracture, despite the osteosynthesis performed. (Uncontroverted fact, given the statements of the CCSS representation in its brief responding to the claim, in association with folio 20 of the precautionary measure bundle and the testimony in court of Dr. Javier Francisco Soto Fallas, who knowledgeably explained the matter in court, regarding the patient's condition at that moment and what had been recorded regarding the failure in the related procedure). In this way, from Hospital San Juan de Dios, a counter-referral was issued on the same day, April 17, 2012, so that he could be treated at the INS. On this matter, Dr. Javier Francisco Soto Fallas explained in court with certainty and expertise that for action to have been taken in the manner it was, as we have indicated, there would have been medical reasons in what is most relevant. Irrelevant for the resolution of the present matter being whether or not there was medical malpractice on the part of the INS medical staff, particularly the doctor who surgically intervened on the plaintiff, Mr. Max Rojas Carranza; witness Javier Soto Fallas reported that despite the INS having performed a procedure on the plaintiff known as osteosynthesis, by means of which the intent is to reposition the fractured bone in a position such that its consolidation is achieved through the placement, among other elements, of screws or, as the case may be, plates, the truth of the matter is that upon receiving the patient, it was observed that the bone was displaced and, in that understanding, the screws intended to achieve the opposite were poorly implanted, so on two levels, what was medically appropriate, first, was that, dealing with eventual complications presented in the procedure, it should be the same doctor who performed the intervention who examined the plaintiff again, determining what complications occurred in the specific case, as well as the necessary corrections that should be applied to alleviate the patient's health problem. On the other hand, he explained in response to questions asked by the Tribunal, that there was also a deontological, if not ethical, issue, which compelled the treating physician at the INS to return to the evaluation and correction of the patient's situation, if his actions could not alleviate the problems Mr. Badilla suffered—the fracture—this being associated with the duties that prevail in the exercise of the medical profession as understood by this Tribunal. That being the situation, it was Mrs. Mayra Torres Tapia who went to the INS to implore insistently—as she stated with clarity in her deposition as a witness in court, without any reason to doubt the truthfulness of her statement—for Mr. Gilberto Badilla Castro to be given care, given that he would not receive it at Hospital San Juan de Dios according to said counter-referral, a request that was rejected with the exclusive reason that the policy coverage had been exhausted, referring him again to the CCSS, with a referral and discharge summary, but without the patient being assessed again. (This corresponds to a fact uncontroverted in part, given the statements of the INS representation in its brief responding to the claim, which does not reject that circumstance, in relation to the declaration of Mrs. Mayra Torres Tapia in the supplementary oral hearing). Given the above, on April 20, 2012, Mr. Gilberto Badilla Castro presented himself at Hospital San Juan de Dios, where, without being assessed again and for the same reasons for which he had been referred to the INS, the CCSS medical staff insisted that he had to be treated at the INS, although he was given a follow-up appointment for April 26, 2012—without a shadow of a doubt that the position continued to be that the INS should be the one to treat Mr. Badilla. (Uncontroverted fact, given the statements of the CCSS representation in its brief responding to the claim). Dr. Javier Francisco Soto Fallas was clear that the aforementioned appointment would serve to decide how to act depending on the treatment given to the plaintiff at the INS, and whether or not he was attended to, and how.

Be that as it may, on the day his follow-up appointment was scheduled, namely April 26, 2012, the plaintiff was received at Hospital San Juan de Dios, where that same day it was recorded—once again—by a note from the treating physician Javier Francisco Soto Fallas, in which he recorded the following: “Patient referred from INS due to policy exhaustion. However, he presents today with a history of left femur fracture at the hip level with a transcervical line; surgery was performed at INS on 03/17/2012 with failure of the osteosynthesis; he presents with migrated screws and displaced head and neck. At this time, operating is not considered an emergency and from a medical-legal standpoint it is a complication of the surgery performed by the INS physician, who must assume it clinically with limitation of hip flexion due to its displacement,” that is, that a surgical procedure applied to the patient, through which external devices such as screws, plates, nails, etc., are placed to align and/or unite the bone or its fragments in order to promote fracture consolidation, through the formation of bone bridges and newly formed or new blood vessels that in both cases allow the transfer of the inputs the bone uses to consolidate, this had not been achieved. The plaintiff was transferred to his home, with performing an operation not being deemed an emergency even in that state, it being further estimated, and principally, that the condition he presented was associated with or was the product of the osteosynthesis procedure applied to him by INS without a positive result. (Folio 116 of the clinical file of Hospital San Juan de Dios, in its volume I, in relation to folio 34 of the same file in its volume II, the representations of the CCSS in its answer brief and the trial testimony of doctor Javier Francisco Soto Fallas). The failure in the procedure had already been detected by the INS medical personnel as stated before, as of the very day of April 17, 2012, at which time a complication associated with the patient's obesity was mentioned. Meanwhile, neither at Hospital San Juan de Dios nor at INS was the plaintiff found being treated with a view to correcting his hip fracture. Finally, the plaintiff resorted to this Jurisdiction in a precautionary action ante causam, as a result of which on May 30, 2012, the order identified with number 266-2012 was issued within this case, by virtue of which the CCSS was exclusively ordered “... to provide comprehensive medical care to Mr. Gilberto Enrique Badilla Castro for any health condition he may be suffering, whether due to the consequences of the traffic accident itself that he suffered, or due to the surgical operations and/or treatments that may or may not have been performed on him by third parties without any distinction whatsoever.” (See folios 88 to 96 of the precautionary measure file). Whether or not the plaintiff was summoned by that medical center previously for a date prior or subsequent to the adoption of the precautionary measure, it is correct to state that he was not summoned to undergo any procedure that, as will be seen, was necessary to correct the fracture he presented in his hip, when rather, on hearing the trial statements of doctor Soto Fallas, it was to decide what to do depending on what INS did on its own, this, despite the fact that the plaintiff's care having been rejected at INS, the plaintiff had also been rejected at Hospital San Juan de Dios on two occasions with knowledge of that circumstance, while the fracture he presented did not consolidate due to the result of the procedure performed at INS, or if applicable, due to complications inherent to the plaintiff's physical circumstances—which we insist, is irrelevant, to the extent that the plaintiff was not being treated in any case to directly correct his ailment—. Thus, it was by reason of what was ordered in the precautionary measure that the plaintiff was received again at Hospital San Juan de Dios on May 31 (a fact not controverted in part, in conjunction with the statements of Mrs. Mayra Torres Tapia), at which time the relevant preparatory examinations were performed, and it was determined necessary to alleviate his condition—the fracture—to carry out surgery, which was successfully performed on him on June 25, 2012. Nothing allows us to state that this could not have been determined weeks earlier. In that operation, Mr. Badilla underwent a total hip replacement, not without first removing three cannulated screws placed by INS in due course as is clearly inferred, and prior to the intervention it had been verified that the plaintiff presented death or disappearance of bone material. (Folios 02 to 24 of the clinical file of Hospital San Juan de Dios, in its volume I, in relation to the trial testimony of doctor Javier Francisco Soto Fallas, folio 84 of the precautionary measure file and folios 21 and 22 of the principal file). Doctor Javier Francisco Soto Fallas explained at trial that the normal or usual procedure for a hip break is to hospitalize the patient and operate surgically, to adopt the necessary actions, either for the fracture to consolidate properly, or to replace the hip. On the other hand, he also explained that the procedure identified as osteosynthesis that was performed on Mr. Gilberto Badilla Castro at Hospital La Católica at the request of INS, was performed with a failure that, if not delaying, prevented the consolidation of the hip fracture he presented. (The trial testimony of doctor Javier Francisco Soto Fallas). It must be emphasized that whether or not the plaintiff was insured by INS, at the time he suffered the traffic accident and was treated at both hospitals, he was insured by his employer as an employee with the Caja Costarricense del Seguro Social, worked as a private security officer, and was in a common-law union with the person identified as Mayra Torres Tapia, the latter, who was responsible for caring for the plaintiff during his convalescence, in what occurred in his home. (Fact not controverted, in relation to the statements of both the plaintiff in his complaint, and at trial, by Mrs. Mayra Torres Tapia, and folio 11 of the precautionary measure file, 79 of the principal file). It was also held as accredited that from April 17 to May 31, 2012, neither at the CCSS nor at INS did their personnel consider themselves responsible for providing direct and principal treatment to the plaintiff aimed at correcting his state—the fracture—. (Fact not controverted) 5.2.- It is concluded from the foregoing that the CCSS, through the service provided to the plaintiff at Hospital San Juan de Dios through its officials, incurred in abnormal conduct in the matter of providing medical services, which constitutes conduct misaligned with the legal system and a cause for imputing patrimonial liability, in an exclusive causal link in relation to the subjective moral damages claimed by the plaintiff, but partially, as was stated earlier and as of the moment it denied one of its insureds the medical care that it is finally known he required, under the argument that this corresponded to INS. It must be noted that whether or not the reasons that, from the perspective of the Hospital San Juan de Dios officials, led them to refer the patient to INS were correct, the fact is that upon his care being rejected at that Institute, it was imperative to treat him without any delay, or if applicable, to inquire with INS as to its reasons in order to proceed immediately to define what to do with the plaintiff. Analyzing the scope of mandatory motor vehicle insurance is of no relevance for the purposes of the CCSS, when in any case the plaintiff was a direct insured as an employee under the regime administered by this sued Public Administration. Thus, the medical authorities of Hospital San Juan de Dios should have noted that, regardless of whether the patient presented a problem associated with a failure in the procedure performed by INS, and whether in their opinion, for medical reasons or for civil liability reasons, it was up to INS to correct the problem, the fact is that it was the plaintiff's prerogative to decide whether he wished to be treated by the CCSS or not. Even though his opinion was sought in this regard, it can be seen that as of April 17, 2012, at least it was known—or at least it should have been known by the medical personnel of Hospital San Juan de Dios—that the plaintiff had been referred by INS, on the grounds that his policy had been exhausted, which could foreshadow the fate Mr. Badilla would meet when he presented himself before that insurance company. Thus, before counter-referring the plaintiff to INS so that he would be treated under his policy and/or if applicable, due to a medical duty imposed for medical reasons and/or by deontological principles, the fact is that a potential rejection of the patient was an entirely expected or at least possible possibility—as indeed it was—. Nothing suggests that it was not the duty of the CCSS to treat the ailment the patient was suffering from efficiently and directly without prejudice to what was done by the INS medical personnel, the plaintiff being a direct insured of the regime administered by the CCSS and at least, if it was deemed that his care had to be provided by INS, having received the plaintiff after his care was rejected by INS—that circumstance being known—the least that could be expected was that before counter-referring the patient, it should have been verified with INS whether he was going to be treated beforehand or not, instead of leaving the patient to his own fate, as was done illegitimately. Access to health services for an insured like the plaintiff cannot be conditioned on or left to a third party without having certainty that he will be treated. In the plaintiff's case, in addition to the foregoing, according to the trial statements of doctor Javier Francisco Soto Fallas, the normal procedure for a hip fracture case is surgery, in order to, through it, correct the position of the bone—for which the implant of screws or plates can be used—with the purpose of placing the bone structure in a position that seeks an adequate consolidation of the fracture. Furthermore, consistent as his testimony was with that given by Mrs. Mayra Torres Tapia, two days after this intervention was performed, it is expected that the patient may even be able to take steps. Contrary to this, improperly, it was imposed on the plaintiff, given the conflict between both institutions over the responsibility for performing this procedure, which was in any case necessary for the plaintiff according to what was done by the CCSS as of May 31, 2012, to wait, even indefinitely while the dispute continued, until it was only through the precautionary intervention by judicial order issued against the CCSS, that the plaintiff was given the proper care. From the foregoing, it follows that the plaintiff indeed suffered abandonment in terms of the provision of health services that should have been timely provided, and this circumstance was maintained at least from April 17 to May 31, 2012, as the plaintiff reproached and according to the cause of action expressed in his complaint, as a consequence of which, it follows that there was administrative conduct on the part of the CCSS medical personnel adopted in misalignment with the legal system, which corresponds with abnormal conduct in the matter of providing services, from which, as will be seen, damage emerged that must be compensated for the plaintiff as he is not obligated to bear it and there being no cause whatsoever that breaks that causal link that must exist according to the doctrine informing the provisions of Article 41 of the Constitution and Article 190 of the Ley General de la Administración Pública.- 5.3.- Having systematically analyzed the evidence in this regard, it follows principally from the statements of Mrs. Mayra Torres Tapia in the complementary trial hearing, in conjunction with the rules of experience, that the plaintiff's desire between April 17 and May 31, 2012, was to be relieved of the intense pain he suffered, as well as to free himself from his incapacitating condition that prevented him from moving on his own, aggravated by his obesity and caused by the existence of a fracture in his hip resulting from a traffic accident. During that period of time, the two sued institutions, initially called upon to resolve his situation accordingly, denied him care, for different reasons. Setting aside the considerations that will be made regarding INS, it is clear that the plaintiff was not only aware of his right to be treated by the CCSS by virtue of being a direct insured as an employee, but also of the injustice represented by the denial of service. On the other hand, Mrs. Mayra Torres Tapia's statements were clear and credible, insofar as they were directed at describing the physical and emotional state of the plaintiff during that period of time, within which, for his care, given among other things his economic conditions, prevented providing conditions for his care, or at least so that his wait might be as comfortable as possible. In fact, she described how the plaintiff had to remain for hours and for days without anyone assisting him at home from early morning hours until night, as well as she elaborated in describing the precarious economic situations they went through. She was also emphatic in informing this Court how she witnessed the plaintiff experiencing great pain, as well as feelings that this Chamber could not refrain from describing on its own, such as impotence, anguish, unease, frustration, anger, sadness, desperation, negative alterations in his character and ability to interact with the person who was caring for him insofar as she could—his common-law partner, Mrs. Mayra Torres Tapia—even desires not to live, all caused by the fact that neither at the CCSS nor at INS did their personnel consider themselves responsible for providing him direct treatment aimed at correcting the state in which he found himself, while he experienced intense pain and serious difficulties in attending to his most basic needs, given that among other things, he was unable to fend for himself. The simplest rules of logic associated with experience, as well as the statements of doctor Soto Fallas, in which he agreed that a situation like the plaintiff's produces pain for which, clearly, each person has a greater tolerance capacity, attest that if the plaintiff had to fend for himself during that period of time as Mrs. Torres Tapia stated when she could not look after him while she worked from seven in the morning until eight o'clock at night, undoubtedly to attend to his simplest needs he must have experienced great pain—to which is added that the input formerly placed to prevent the mobility of his hip had been removed—. The feelings described, associated with his being aware that his right to health was being injured, would undoubtedly in any person have caused a strong feeling of frustration and anxiety. However, this Court considers that the applicable liability shall not be joint and several, because the criterion for imputation is very different from that applicable to the INS case as will be seen, in addition to the fact that we consider that the sum claimed is not consistent with the intensity with which the plaintiff experienced the harmful effects described. The legal nature of this entity and the service it provides through the hospitals it administers, we consider, imposes a greater reproach of liability compared to that which can be attributed to INS, which provides services of a private nature. Thus, we deem reasonable and adequate to the merits of the circumstances the plaintiff endured, to award the sum of fifteen million colones as subjective moral damages, which must be paid by the CCSS in favor of Mr. Badilla Castro once this judgment becomes final, as is hereby ordered.- 6.- Regarding the partial validity of the claim against the Instituto Nacional de Seguros. With respect to the Instituto Nacional de Seguros, this Chamber is of the opinion that having denied care to the plaintiff after his insurance policy was exhausted as to the amount of its coverage, while in principle conformed to what the Ley de Tránsito por las vías públicas Terrestres dictates, cannot be considered conduct in accordance with law, if the legal system is applied in its entirety to the specific case, but in the matter of the provision of medical services through the operation of a hospital center. This Court is of the opinion that a separation must be made here between what constitutes a provision of services under the content and scope of an insurance contract and what corresponds to the obligations imposed by the legal system in a different matter, which is the provision of services such as those provided to the plaintiff once he was accepted as a patient at the Hospital administered by INS. On this particular topic, the existing regulation is of direct application to INS insofar as it treats a patient at its hospital center, encompassing the right under constitutional and international law, which establish as a fundamental and human right, the right and access to health services, which at all times must be comprehensive and must place at the apex of whatever institutional interest there may be, the well-being, also comprehensive, of the treated subject. We must start from the fact that it was held as a proven fact that the opinion of the CCSS doctors upon receiving the plaintiff after surgery was performed on him at INS, was that he presented a failure derived from the procedure that was performed on him, which prevented consolidation of his hip fracture, so that it was their view, even for medical reasons, that he should be treated by the same doctor who performed that failed procedure on him. The core issue is to determine whether the actions of INS, in application of what it understands to be the scope of mandatory motor vehicle insurance, have the power to exclude its liability. The answer is negative in this chamber's opinion. We must insist that whether an insurance contract exists or not, upon a patient being received by INS and being given medical treatment on its account, it is at the same time governed by the regulations prevailing in the matter of the provision of medical services, the operation of hospitals, the duties and rights of persons using these services, and correspondingly, both from the Reglamento General del Sistema Nacional de Salud and the Código de Moral Médica that govern the professional practice of the officials who treated the plaintiff directly and/or, from their position as hospital medical authorities. We will begin by saying that after the surgery performed on the plaintiff, the referral made of him to the CCSS on the grounds that his policy coverage had been exhausted, is not by itself a circumstance for which liability should be reproached against the company. A different thing occurs after care is denied to the plaintiff and the manner in which this was done, as of the time he is counter-referred by Hospital San Juan de Dios. Firstly, this not having been denied by INS's representation, through Mrs. Mayra Torres Tapia, INS was implored for care for the plaintiff on the occasion that the CCSS was denying him service and he was experiencing great pain. INS's refusal to receive the plaintiff again, based exclusively on the exhaustion of his policy, is not admissible, the duty of its medical personnel being to have inquired about the reasons why he was being referred back from Hospital San Juan de Dios. This was entirely omitted in the face of the requests made on behalf of the plaintiff, she being duly authorized to do so, by Mrs. Mayra Torres Tapia. The plaintiff presented a failure in the medical procedure performed by INS, in the opinion of the CCSS, so that its personnel had the responsibility of verifying whether or not this was so at least, in order to later decide—whether costs are generated or not—how to proceed with the patient who was already known, and was not being accepted by the CCSS. Contrary to this, it decided simply not to assess the plaintiff's case and to leave him to his own fate, knowing that at Hospital San Juan de Dios he was not going to be treated. A minimum of diligence in the face of the plaintiff's situation would have been that before denying him care, it should have verified with the personnel of Hospital San Juan de Dios whether they would receive him back or not. The counter-referral to INS was made—rightly or wrongly and among other reasons—based on medical, even deontological reasons as was affirmed by the Hospital San Juan de Dios doctor, doctor Javier Francisco Soto Fallas, so that the denial of care by INS would have been expected to be based on reasons of the same nature, and not contractual reasons based on the scope of an insurance contract, since in its activity the provision of health services merges with that of an operator in the insurance market, without this latter activity excluding the regulations governing the operation of a hospital. Within the framework of providing hospital services, it is not superfluous to indicate that Decreto Ejecutivo No. 19276, of November 9, 1989, Reglamento General del Sistema Nacional de Salud, provides that INS, together with the CCSS and the rest of the public and private institutions indicated therein, form part of said system, and must act in an articulated, that is, systematic and coordinated manner. Its Article 9 states that: “In order to guarantee comprehensive health care for the entire population, the right of all citizens to receive health services is recognized, in the facilities of the Ministry of Health, the Caja Costarricense de Seguro Social and the Instituto Nacional de Seguros, consequently, the provision of comprehensive health services may not be denied to any particular person, without prejudice to subsequent verifications and corresponding charges when they apply.” An integral part of the system according to Article 11 is INS, which is conceived as a: “... institution that helps to reduce, in a broad and socially beneficial manner, the economic uncertainty that individually and collectively the members of the community face. It is its responsibility to help prevent occupational and traffic misfortunes and to provide injured persons with comprehensive medical, hospital and rehabilitative services.” (Highlighting is not from the original). While for its part, Article 13 reads as follows: “Health establishments shall be articulated among themselves in networks of service supply according to levels of care, capable of offering universal coverage with services at the first level of care and staggered access to levels of greater complexity, as appropriate to the user's need.” For this Court it is clear that at the time of the counter-referral from Hospital San Juan de Dios to INS, just as later occurred as of May 31, 2012, what the plaintiff required was surgery to correct his hip fracture, even with the procedure performed by INS or as a consequence thereof, this based on reasons among others, of a medical nature, it being ideal that he be treated by the same physician who performed the procedure that failed for the consolidation of the hip fracture as he was the professional best positioned to determine what complications might have arisen in the patient. Finally, according to Article 42 of the same regulatory body: “The basic functions of Hospitals are the following: (...) 3) Coordinate activities with centers of greater and lesser complexity in the health services network and with the committees representing the communities.” Thus, it is determined that there is a duty of coordination in any case imposed on INS, not to leave one of its patients to his own fate when faced with a referral to another medical center, especially under the plaintiff's circumstances and, additionally, on the occasion of being counter-referred for medical and liability reasons in that sense. From an ethical—if not deontological—standpoint, the Código de Moral Médica, Decreto Ejecutivo No. 35332 of May 15, 2009, imposes on the professional in its Article 22, that: “... must not abandon his responsibilities towards his patient, even temporarily, without leaving another qualified and informed doctor to replace him in the care of the former, except for a fully demonstrated force majeure reason.” This speaks of the possibility of being relieved of the care of a patient, to transfer him to another professional. What is applicable to the specific case, because the plaintiff is referred to a medical center that refers him back for medical reasons about which no inquiry was made, only to later reject his care, it is insisted, not for medical reasons, but rather contractual reasons of a nature different from the science at hand. In any case, Article 34: “Regardless of where the practice of the profession is carried out, the interests and integrity of the patient must be respected.” Article 36: “The doctor, from the moment he has been called to provide his care to a patient and has accepted, is obligated to ensure him, immediately, all the medical care within his power, personally, or with the help of qualified third parties.” Article 42: “The doctor must provide all pertinent information to the patient, at the time of transferring him for purposes of continuity of treatment, upon ending the doctor-patient relationship or if the patient requests it.” (Highlighting is not from the original). Finally, Article 63: “The doctor's relationships with other professionals and support personnel in the health area must be based on mutual respect, on the professional or labor freedom and independence of each one, always seeking common interests for the patient's well-being.” (Highlighting is not from the original). Thus, the legal system demands not being indifferent in the face of a counter-referral such as that given to the plaintiff by Hospital San Juan de Dios, whether or not its medical personnel's opinion is correct. At least the plaintiff should have been seen to assess him and thereby determine whether or not it was the responsibility of INS to correct a treatment or procedure poorly executed in its entirety and for which it was responsible before the patient, in which case if INS proved to be responsible, whether or not his policy was exhausted, there is no doubt that the duty to correct the patient's problem prevails if he so requires or demands it, at no cost for reasons of medical liability as the CCSS doctors warned. This Court observes that what was done also disregarded the Ley sobre derechos y deberes de las personas usuarias de los servicios de salud públicos y privados, No. 8239, Article 2, subsection e), which provides as a right of these users to receive care efficiently and diligently. Article 50 of the Ley General de Salud states that: “The professionals or authorized persons to practice in health sciences responsible, by reason of their profession, for the technical or scientific direction of any medical care establishment, pharmacy and the like, shall be jointly and severally liable with the owner of said establishment, for the legal or regulatory infractions that may be committed in said establishment,” which reinforces to some degree what was done under the terms already stated by the medical professionals who counter-referred the plaintiff to the Hospital San Juan de Dios to INS, and correlatively would have imposed on the Institute the duty to at least assess the plaintiff to determine his fate. Another matter is that, as was warned, the CCSS, knowingly regarding INS's position, insisted on its position to the detriment of the affected person's interests.

It should have been taken into account, according to the statements of doctor Javier Francisco Soto Fallas, that it is rationally acceptable that the suitable professional to determine the health conditions of the plaintiff and the treatment to be followed is the treating physician, in this case, the one who performed the procedure because he is the one who best knows what he did and can establish from there which health services the user of the system is entitled to, based on a relationship that should exist between the scientific knowledge possessed by the professional and the patient’s clinical history. We understand from this perspective that an entity that is part of the National Health System, in this case the INS, cannot deny a medical service under the circumstances in which the plaintiff found himself, arguing exclusively that there is no longer coverage under the policy, or that it is not included in its benefits plan, when, on the contrary, in cases like the present one, it is the duty of the entity to have all the elements that, from a medical point of view, are necessary to adequately support the decision to authorize or deny the service to the patient, which it did not do. We add to the above that even in the matter at hand, a responsible party is one who has the legal duty to repair a harm, even if it did not cause it directly or materially, which is fully applicable to cases of medical liability insofar as it implies, among other aspects, the obligation of physicians to repair and satisfy the consequences of acts, omissions, and even voluntary and involuntary errors, within certain limits of course, committed in the exercise of their profession. In insurance matters with respect to the INS, we also have that the insurance splits, on one hand tending to repair the damage caused and nothing more, or in its case to take charge of the treatment of the patient or user; here the application of regulations different from those governing the insurance market and its products comes into play. In the case of medical activity, all those involved directly or indirectly in the occurrence of the harm are liable, such as the physician, the clinic or hospital, the assistants, and the insurers, such that a medical center cannot shelter itself in the fact that, as a business organization, the same deontological rules that govern its professionals are not applicable to it. Having said the above, it is the opinion of this Court that although the legal system may not have imposed that it be the INS that corrected the failures of the procedure it performed on the plaintiff, it was indeed obligated to rule out its liability in light of the information contained in the counter-referral given to Mr. Badilla Castro by the physicians of the Hospital San Juan de Dios, which imposed on it at least the duty to have evaluated him. As a result of its actions, and as indeed happened in reality, the plaintiff’s situation—insofar as he did not receive attention in either of the two hospitals—was unjustifiably prolonged as a barrier to timely access to the health services to which he was entitled, in the face of a condition that has the potential to affect the quality of life of any person due to how incapacitating the injury suffered was, in addition to being painful. With this, the INS, through its conduct, contributed to the moral harm (daño moral) experienced by Mr. Badilla Castro, a situation that allows the claimed liability to be imputed to it, albeit autonomously, as was the case for the CCSS, and for different reasons as we have explained. It is not acceptable that exclusively under the protection of the "Ley de Tránsito" and the coverage of the plaintiff's insurance, it was legitimized to have acted in the way that it did. The conduct thus displayed constitutes an abnormal one in the matter of health service provisions, which generated a harm of the same subjective moral nature for which the CCSS was found liable. However, given the participation in the events by this state enterprise, it is estimated that the reproach or imputation to be made against the INS is lesser; therefore, it is estimated that the subjective moral harm (daño moral subjetivo) should be compensated in the amount of five million colones, and that is hereby ordered, as that amount is deemed adequate. As a separate note, this Court cannot let the opportunity pass to refer to an aspect of the attention given to the plaintiff, which it is estimated should be reviewed by the medical authorities of the INS. We consider that the patient must be informed adequately and with as much precision as possible, given his condition and the projection of the care he will receive from the medical staff of the INS, at what point his policy will be exhausted and what the consequences of that will be, so that he has the opportunity to decide in an informed manner whether he would prefer to be treated at another care center. It is not observed that this is currently happening, at least based on the case under study, and therefore the defendant Institute is urged to take note of this observation for present and future occasions.- 7.- Regarding the inadmissibility of the petitionary claims of an indemnity nature for the alleged lack of a disability subsidy, and for expenses associated with the purchase of medications. In a manner that is inherently confusing, the plaintiff petitioned the following as a claim for damages and/or losses against both defendant entities jointly and severally: “1. For the damage caused by the forty-five days without attention to my health, during which I found myself completely deprived of medical assistance and the lack of subsidy and disability during that time, in the amount of six hundred seventy-two thousand four hundred thirty-three colones and sixty-five céntimos.” From the damage claimed, one can barely identify that constituted by the lack of a subsidy and medical disability—we must understand—that he would have suffered during the time in which he would not have been attended by either of the defendant parties, since both refused to provide attention to the patient. This being so, with respect to the unidentified damage, no analysis shall be made on the matter, as this court is not ordered to speculate when it instead falls to the party to be clear in what it petitions. On the other hand, regarding the vaguely stated subsidy and disability, as well as the claim for medical expenses to be paid against invoices, the majority of which do not identify the purchaser of various pharmaceutical products, it is sufficient to indicate that the claim is dismissed, on the grounds that it was not proven by the plaintiff that, having requested the supply of medications from the CCSS within the period that elapsed from April 17 to May 31, both of 2012, they were denied, nor that he was likewise denied disabilities or the delivery of the respective subsidy, all in the absence of evidentiary elements that allow the contrary to be affirmed. Furthermore, although mention was made of mistreatment of the plaintiff at Hospital San Juan de Dios by its staff, it is not among the claims that any recognition is being sought for that, moreover, supposed reproach, and therefore no analysis will be made on the matter.- VIII.- Corollary. The plaintiff only partially proved the conditions that, under the legal system, make the liability reproaches brought against the defendant entities admissible, in the terms set forth in this judgment. In what was not proven, the claim must therefore be dismissed, that is, with respect to the alleged damage identified as or associated with the absence of subsidy and disability, as well as the payment for expenses—invoices—that he claimed to have incurred due to the conduct displayed by the defendants. In what was found admissible, given that both defendant entities illegitimately affected the plaintiff’s right to health and access to medical services, they are autonomously ordered to pay: the Caja Costarricense del Seguro Social, the sum of fifteen million colones, and the Instituto Nacional de Seguros, the sum of five million colones, in both cases as compensation for the moral harm (daño moral) caused, all effective from the finality of this judgment.—” The Constitutional Chamber (La Sala Constitucional) has been responsible for dimensioning this right and thus, in its judgment number 2010-07602 of 14:49 hours on April 27, 2010, indicated in this regard that: *"The World Health Organization (WHO), in its Constitution—adopted in New York in 1946—defined health as a state of complete physical, mental, spiritual, emotional, and social well-being, and not merely the absence of affections or diseases. Regarding the right to health, in a broad sense, what was stated by this Court in Vote No. 1915-92 of 14:12 hrs. on July 22, 1992, is illustrative, which, in what is of interest, points out the following: "(...) the right to health has as its fundamental purpose to make effective the right to life, because this does not protect only the biological existence of the person, but also the other aspects derived from it. It is rightly said that the human being is the only being in nature with teleological conduct, because they live according to their ideas, ends, and spiritual aspirations; in that condition of being a cultural being lies the explanation for the necessary protection that, in a civilized world, must be granted to their right to life in all its extension, consequently to a healthy life. If within the extensions that this right has is, as explained, the right to health or health care, this includes the State's duty to guarantee the prevention and treatment of diseases (...)". Likewise, categorical is what was stated by this Chamber in Judgment No. 11222-03 of 17:48 hrs. on September 30, 2003, when stating the following: "(...) VI.- FUNDAMENTAL RIGHT TO HEALTH. The right to life recognized in numeral 21 of the Constitution is the cornerstone upon which rest the other fundamental rights of the inhabitants of the Republic. In the same way, in that ordinal of the political charter, the right to health finds its anchor, since life is inconceivable if the human person is not guaranteed minimum conditions for an adequate and harmonious psychic, physical, and environmental balance (...)"*. In this way, it must be underpinned that the aforementioned fundamental right is guaranteed through actions aimed at preserving human life in minimum conditions that foster an integral, adequate, and harmonious psychic, physical, and environmental balance, all of which, of course, is directly applicable to the operation of hospital centers, as well as the practice of medical science, among other activities and sciences, as well as diverse professions, which in their practice affect this topic. Moreover, the right to health is recognized at the level of international law, article 25 of the Universal Declaration of Human Rights; 7 and 1 of the American Declaration, 3, 6, 23 and 24 of the Convention on the Rights of the Child. Consequently, and without losing sight that the legal operator must observe the principle of conventionality control, both the right of the Constitution and any instrument of international law that protects a right of this kind with greater force than the former, shall inform the interpretation and application of the infra-constitutional normative order in solving problems in concrete cases. Being our interest the topic linked to the provision of medical services, see also what was indicated by the Constitutional Chamber (La Sala Constitucional) in its judgment number 2011-003683 of 15:47 hours on March 22, 2011, in which the following was indicated: ***“****It is enough just to consult the International Covenant on Economic, Social and Cultural Rights, in its numeral 12, to become aware of what we have been affirming. Indeed, in said international human rights instrument, the right of every person to enjoy the highest possible level of physical and mental health is clearly established, and therefore the State and its institutions have the duty to ensure the full effectiveness of that right through a series of positive actions and the exercise of regulatory, supervisory, and sanitary police powers. The foregoing means, no more nor less, the prevention and effective treatment of diseases, as well as the creation of conditions that ensure everyone medical assistance and quality medical services in case of illness. Having said that, the right to health comprises the availability of health services and programs in sufficient quantity for the users of these services and the recipients of these programs. On the other hand, the right to health also entails accessibility to these services and programs, whose four dimensions are non-discrimination in access to health services, physical accessibility—particularly for the most vulnerable—, economic accessibility—which entails equity and the affordable nature of health goods and services—, and accessibility to information. No less important is that health services and programs are acceptable, that is, respectful of medical ethics, culturally appropriate, aimed at improving patients' health, confidential, etc. Finally, and no less relevant for that, the right to health implies quality services and programs, which means that such services must be scientifically and medically appropriate”.* Now then, taking the foregoing into account, we shall proceed to the analysis of the admissibility or not of what was petitioned in the complaint known in the terms of this instrument.- **3.- Regarding mandatory insurance for automotive vehicles.** We deem it opportune, for being synthetic yet integral, to quote what was stated in this regard by Section VIII (la Sección VIII) of this Court in its judgment 110 - 2013 of 15:00 hours on November 28, 2013, an opportunity in which on this topic the following was stated: *"IV.- (...) The so-called Mandatory Automobile Insurance corresponds to an instrument of protection and economic support (contractually concretized between the owner of a vehicle and a public or private insurer) for those possibly affected in a traffic accident, which is imposed by the legal system on vehicle owners as an authorizing requirement for their movement within the national territory. Through it, drivers, passengers, and third parties—passersby or travelers—are covered in relation to the risk generated by the activity of driving an automobile, which can eventually cause the death of citizens, or their total or partial incapacity, as well as medical, hospital, and rehabilitation expenses, per diems, food, or other cases—according to the parameters of the insurance—, covered through subsidies, in the event of a traffic accident. Certainly, ***it carries an implicit public interest that, it must be clarified, does not imply a transmutation of said mechanism into a social insurance, since the duty of its acquisition is linked and directed to the ownership of a vehicle and, consequently, whoever takes it out will establish a private contractual nexus with the insurer entity that provides the service***. In that line, it must be highlighted, the limit of the quantum of the subsidies that are eventually granted is subject, on the one hand, to the type and degree of the injuries caused and, on the other, ***to the sum agreed upon between the private individual-insured and the insurance company, which is generally defined in an adhesion clause of the contract, which varies each certain period***. In parallel, that insurance entails an element of protection of the patrimony of the vehicle owner (or its driver) responsible for the injury, who may unexpectedly face an economic tension upon the unforeseen causation of an injury, so the Mandatory Automobile Insurance (SOA) also functions as a means of compensation or balance of the patrimony of the person causing the damage, even though, eventually, that responsibility may exceed the agreed coverage, in which case, ***once the insurance amount is satisfied, the insurer entity disengages from the matter***, leaving the generator of the detriment directly obliged by constitutional imperative (numeral 41 of the Magna Carta (la Carta Magna)), which was already indirectly addressed regarding mandatory insurances by the First Chamber (la Sala Primera) of the Supreme Court of Justice (la Corte Suprema de Justicia) through vote No. 30-F-2005 of 10:45 hours on January 27, 2005. From a normative perspective, the Mandatory Automobile Insurance (SOA) has its origin in the Traffic Law, namely, No. 5322 of August 27, 1973, repealed by Law No. 5930 of September 13, 1976, which in turn was substituted by the Traffic Law on Public Land Roads, No. 7331 of April 13, 1993, and its subsequent reforms. On the date when the accident giving rise to this process took place, the insurance amount was determined at three million colones, and Law No. 8696 of December 17, 2008, was applicable, as well as the Regulation on Mandatory Insurance for Automotive Vehicles No. 25.370-MOPT-J-MP of July 4, 1996. In general, we proceed to refer to the legal bases of importance for this type of insurance. Thus, ordinal 39 of the Law establishes the mandatory nature of said instrument, providing at the same time the basis for the issuance of the regulatory regulation. Numeral 49 expressly states: “The mandatory vehicle insurance covers the injury and death of persons, victims of a traffic accident, whether or not there is subjective responsibility of the driver. Likewise, it covers accidents produced with civil liability, derived from the possession, use, or maintenance of the vehicle. In this last case, this responsibility must be determined through established procedures and before competent courts." For their part, ordinals 52 and 53 define the limits and the admissible economic benefits, and 51 indicates that the maximum coverage limit for mandatory vehicle insurance will be defined by the regulation to the Law, which is determined by article 14 ...”.* (The highlighting is not from the original). Attention must be drawn to the fact that the National Insurance Institute (Instituto Nacional de Seguros), in what it administers this insurance and, at the same time, directly provides health services through its hospital center, exercises functions that are split regarding their regulation, the first being of a commercial order according to an ordinary and principal economic activity—today liberalized within the framework of the insurance market—and on the other hand, a benefit-related one regarding the provision of hospital services, which, associated or not with the coverage of an insurance policy, corresponds to an activity governed by special regulations, thus informed by the rules of the arts associated with medical science and, in this last measure, by the deontological rules that govern medical action through the professionals in that area through whom a nosocomial acts.- **4.- On the nature of the services provided by the National Insurance Institute.** Even though this topic might seem settled, due to its relevance for the issuance of this ruling, it must be revisited. A special normative body on the matter, implemented for the first time, can be located starting from October 2, 1922, with Insurance Law number 11, published in the corresponding Collection of Laws and Decrees of that year, second semester, first volume, page 314, at a time when the activity linked to the possibility of mercantilely accepting, in exchange for the satisfaction of a premium, the transfer of risks to which, being insurable, third persons are exposed was liberalized to free competition, so that in the event of the occurrence of any circumstance that, as foreseen, justifies it, an indemnity covering the economic burden that such an event may generate becomes dispensable, due to the harmful effects on the insured's patrimony and/or personal integrity. On October 30, 1924, Law number 12 of that date, today the Law of the National Insurance Institute (Ley del Instituto Nacional de Seguros), was enacted, through which the former Insurance Law was entirely repealed. Through this, an entity named National Insurance Bank (Banco Nacional de Seguros) was created, which would later mutate to an institute. The creation of this organization occurred pursuant to numerals 4 and 5 of said law, foreseeing from then on the future monopolization of the market, being designed, in the meantime, so that the National Insurance Bank (Banco Nacional de Seguros) would serve to contract and execute State insurances. Later, in article 5 of this normative body, the National Insurance Institute (Instituto Nacional de Seguros) was created from the reform operated by Law number 4183 of September 4, 1968, which, related to the subsequent reform operated by Law number 6082 of August 30, 1977, and Law 6082 of the same year, end up establishing the state monopoly, which generated that this activity was found exclusively under the administration of said institute, operating as an autonomous entity. Currently, the Law of the National Insurance Institute (Ley del Instituto Nacional de Seguros) is in force according to the text of its constitutive law, once reformed pursuant to article 52 of the Regulatory Law of the Insurance Market (Ley Reguladora del Mercado de Seguros), number 8653 of July 22, 2008, published in the Official Gazette “La Gaceta” number 152, alcance 3, of August 7 of the same year. This reform came as a consequence of the obligations acquired by the State with its counterparts in the pertinent matter, on the occasion of the adoption of the Free Trade Agreement, United States, Central America and the Dominican Republic, approved by Law number 8622 of November 21, 2007, published in the Official Gazette “La Gaceta” number 246, of December 21 of that same year, alcance 40. The derived commitments that are of interest are located within the annex of the treaty corresponding to financial services and in insurance matters. (See constitutional article 7). Thus, the first article of the Law of the National Insurance Institute (Ley del Instituto Nacional de Seguros), reformed by the Regulatory Law of the Insurance Market (la Ley Reguladora del Mercado de Seguros), established in what is pertinent as follows: *“The National Insurance Institute, hereinafter INS, is the autonomous insurance institution of the State, with its own legal personality and patrimony, authorized to develop the insurance and reinsurance activity. In said activities, the regulation, supervision, and sanctioning regime provided for all insurance entities shall be applicable to it. / (...). / In the development of the insurance activity in the country, which includes the administration of commercial insurances, the administration of the Occupational Risks Insurance (Seguro de Riesgos del Trabajo), and the Mandatory Vehicle Insurance (Seguro Obligatorio de Vehículos Automotores), the INS shall have the full guarantee of the State. / The INS is empowered to constitute or acquire capital participations in corporations, commercial companies, branches, agencies, or any other commercial entity of a similar nature, none of which shall count on the guarantee indicated in the preceding paragraph for the following purposes: a) To exercise the activities that have been entrusted to it by law within the country. Said activities comprise those of a financial nature, granting of credits, ***those of providing health services***, and those pertaining to the Fire Department (Cuerpo de Bomberos), ***the supply of medical benefits***, and the sale of goods acquired by the INS by reason of its activities. / Additionally, the INS may establish, by itself or through its companies, strategic alliances with public or private entities in the country or abroad, with the sole purpose of fulfilling its competence. / Both the INS and its corporations, with the approval of the respective boards of directors, may incur debt prudently in accordance with the corresponding financial studies. These operations will not have the guarantee of the State. / Public banks are authorized to participate as shareholders of the corporations that the INS establishes according to what is indicated in this article, provided that the INS remains as the majority partner of said companies.”* The text, as indicated, corresponds to the historical moment in which, as a product of the scope of the mentioned free trade agreement, the existing monopoly is broken and the insurance market is completely opened to free competition in all its manifestations for products associated with insurance. From the outset, the indicated first article corresponds to a legislative line strongly oriented towards reinforcing the Institute's capacity to act under the private law regime so that, its activity being of public interest, it aims at a successful participation in the free market of products associated with the insurance activity, as part of the state productive sector. The core or epicentral activity of the Institute is, according to its constitutive law, the commercialization of insurance products; however, other activities have also been so, such as associated financial activities, and another, alien to this specific main commercial activity within the framework of a liberalized market, that is conserved residually—one would have to say—as a product of those moments when the activity was under the state monopoly through it, such as the activity deployed by the Fire Department (Cuerpo de Bomberos), which before the reform caused on the occasion of the same Regulatory Law of the Insurance Market (la misma Ley Reguladora del Mercado de Seguros), stood as an organ with minimal deconcentration. Today, it is an organ with instrumental legal personality and maximum deconcentration, attached to the Institute according to the Law of the Meritorious Fire Department (Ley del Benemérito Cuerpo de Bomberos) number 8338 of March 19, 2002, articles 1 and 2. On the other hand, there are the activities linked to medical benefits, which are originated in a direct link with the insurance activity, so that they are medical services through its own hospital centers or third parties with whom it is linked for this purpose, which in both cases correspond to a private service subject to the existence of an insurance contract, marketable by any authorized insurer, different from those that would have to be understood as being comprised within the social security services administered by the Costa Rican Social Security Fund (la Caja Costarricense del Seguro Social), these latter ones regarding which one can indeed affirm their nature as a service open to the public universally. These medical services provided by the Institute, as they could be by any authorized third party, it is insisted, clearly correspond to the effects and scope of the services associated as a benefit to some of its products, such as so-called personal insurances. The constituent advanced something of this, from the content that was given to article 73 of the Magna Carta (la Carta Magna), when determining with a special regime to be developed by the ordinary legislator and different from that corresponding to social insurances for the case of mandatory insurances for occupational risks, erected with the purpose of protecting workers with the burden on their employer, serving as a mechanism for access to health services. It is an insurance that works as an exclusive obligation of the employers towards the workers with whom they are linked, that is, with the burden on their patrimony exclusively and as determined by the corresponding regulations. By reason of this, the employer must obligatorily acquire, within the market, the corresponding insurance product in order to comply with this provision, just as it is mandatory for the owners of automotive vehicles to pay, in order to access the right of circulation, the corresponding mandatory insurance, which would essentially cover the death and/or care of injuries caused by a traffic accident. Currently, the Regulatory Law of the Insurance Market (la Ley Reguladora del Mercado de Seguros), which, as an effect of the Free Trade Agreement pointed out above, fostered the opening of the market to such a degree that both mandatory vehicle insurances and occupational risk insurances were included under the terms of what is provided in Transitory Provision III of that law, related to its article 2, last paragraph, leaving excepted from the application of this regulation, and therefore, outside free trade, only the mandatory social security systems administered by the Costa Rican Social Security Fund (la Caja Costarricense de Seguro Social) and the special pension regimes created by law and the mandatory mutual policy administered by the Life Insurance Society of the National Teaching Profession (Sociedad de Seguros de Vida del Magisterio Nacional), speak to the fact that what the Institute provides in health matters are not social services with the openness of those provided by the Costa Rican Social Security Fund (la Caja Costarricense del Seguro Social). This liberalization could be seen as potable according to the law of the Constitution, since the Constitutional Chamber (La Sala Constitucional) in its judgment number 2001-12952, of sixteen hours and twenty-four minutes on December 18, 2001, affirmed as follows: *“**II.-** The second and third points of the consultation are intimately linked, insofar as they start from the premise that the National Insurance Institute has constitutionally assigned competence in occupational risk matters, which is inaccurate. Constitutional article 73 clearly states that 'Insurance against occupational risks shall be exclusively at the expense of the employers and shall be governed by special provisions,' from which it is concluded that it is the law that is in charge of developing them. Constitutional article 188 merely indicates that the State's insurance entities are autonomous institutions, and from that provision, ***it cannot be validly concluded that the Constitution has granted the INS exclusive competence in occupational risk matters***. Occupational risk insurance, as a State monopoly, has its origin in Law No. 12 of the month of October 1924; by Law No. 33 of December 23, 1936, the National Insurance Institute was born to legal life, to which the competence to ***commercialize, among other types of insurance, the occupational risk insurance that concerns us was maintained***. ***Subsequently, constitutional article 73 established occupational risk insurance “at the expense of the employers,”*** leaving the regulation to ordinary law, which has not undergone any modification, and for that reason, the National Insurance Institute has maintained that competence over the years. The reading of the Minutes of the National Constituent Assembly (la Asamblea Nacional Constituyente) clearly shows us that article 73 was drafted in a broad form to allow, in the future, that what was related to disability, old age, death, and occupational risk insurances would be in a single direction; consequently, the establishment of logical coadjuvancies between State institutions cannot be considered contrary to the constitutional order, for which it is not necessary to comply with the hearing procedure that the consultants miss."* (The highlighting is not from the original).

Now then, the legislator took account of this type of autonomous organizations, such as the defendant Institute, when enacting the General Law of Public Administration (la Ley General de la Administración Pública) number 6227 in nineteen seventy-eight. According to its articles 01 to 3, the Public Administration (la Administración Pública), through its diverse organic manifestations, has capacity under public and private law to act and subsequently, public law being what governs the activity of the State, although it also applies to other public entities different from this, such as decentralized ones, it is so provided no law states otherwise. For this reason, it is possible that private law regulates a specific activity of those entities, when there is a law that so indicates, something that can well occur because, due to their overall regime and the requirements of their line of business, they must be considered as common industrial or commercial enterprises. The foregoing is reinforced if one observes the content of articles 111 and 112 of the same legal body regarding what regulates service relations between the Administration and its agents, when these do not participate in what can be understood as public management, or when they participate in a legal relationship with public enterprises or economic services of the State in charge of operations subject to common law.

By the finalist principle of interpretation of norms and without prejudice to ideological positions that in the past and present may qualify what will be said in different ways, since its existence once the General Law of Public Administration was promulgated, and later, reinforced and qualified after the entry into force of the Securities Market Regulatory Law, the latter informed by the scope of the Free Trade Agreement between the United States, Central America and the Dominican Republic, approved by Law number 8622, it is clear that the legal nature of the National Insurance Institute is that of a state-owned public enterprise, created under a form of Public Law, despite this, created for the provision of commercial services regulated by common law. The organization is located within the framework of what is understood within the productive sector of the decentralized public institutional organization. Article 2 of the Law of the National Insurance Institute must be observed in what it indicates as follows: <i>“Application of Private law. The acts generated from the development of its commercial insurance activity, acting as a common commercial enterprise, shall be regulated by Private law, and therefore, in the exercise of insurance activity, the Institute shall be subject to the jurisdiction of the common courts”</i>. From the foregoing as a derivation, in view of the activity that this entity legally carries out, none of its manifestations is or constitutes a public service, as they do not share its characteristics, except for that associated with fire extinguishing, residing in a person organ that is attached to it, such as the Fire Department, without this particular activity constituting the neuralgic axis of the entity. It should be noted that even including the commercialization of compulsory automobile insurance or occupational risk insurance within the Institute's activity, regardless of the social interest they may have, they are personal insurance products in the insurance market that can now be offered by any authorized participant, and therefore do not differ in any way from the rest of the products associated with this insurance market, becoming commercial goods and services in all their aspects. This assertion is reinforced in the framework of a market liberalization towards free competition in insurance matters, within which the legislator has also committed to strengthening the capacity of this institution to deploy its capacity to act governed by private law, in order to ensure its successful participation in a framework of equality in the market, compared to other participants in it, which has been powerfully projected in its capacity not only to manage its attributions and competencies, but also to self-organize for these purposes. The fact that the assets managed by the Institute constitute part of the public treasury assets does not say anything that does not operate for the rest of the state-owned public enterprises that, like this one, exercise a commercial activity subject to private law, but at the same time, to certain controls that for each institution may vary in degree and intensity. (Articles 8 and 9 of the Organic Law of the Comptroller General of the Republic). Well then, it must be noted, as we indicated above, that whether or not associated with the application of a product within the framework of commercial insurance activity, the conduct deployed towards the plaintiff by the National Insurance Institute, as well as that of the Costa Rican Social Security Fund, was misaligned with the legal system, and therefore, in terms of service provision, they constituted, at different levels, abnormal behaviors that make part of what was claimed admissible as will be seen, since they serve as a criterion for the imputation of patrimonial liability based on the fact that they also constituted the origin of a moral damage intensely experienced by the plaintiff, which must.- </span><span lang=EN style='mso-ansi-language:EN'><o:p></o:p></span></p> <p class=MsoNormal style='line-height:150%'><b><span lang=EN style='font-size: 11.0pt;line-height:150%;font-family:Arial;mso-ansi-language:EN'>5.- On the partial admissibility of the claim against the Costa Rican Social Security Fund. </span></b><span lang=EN style='font-size:11.0pt;line-height: 150%;font-family:Arial;mso-ansi-language:EN'>This Tribunal considers it appropriate to begin this section related to what, according to the facts that have been deemed proven, is relevant for the resolution of the point in question. </span><span lang=EN style='mso-ansi-language:EN'><o:p></o:p></span></p> <p class=MsoNormal style='line-height:150%'><b><span lang=EN style='font-size: 11.0pt;line-height:150%;font-family:Arial;mso-ansi-language:EN'>5.1.- </span></b><span lang=EN style='font-size:11.0pt;line-height:150%;font-family:Arial;mso-ansi-language: EN'>In relation to this part, it is established that on March 8, 2012, Mr. Gilberto Badilla Castro suffered a traffic accident, as a result of which he presented injuries that warranted his transfer to a hospital, in this case, to the San Juan de Dios Hospital. (Uncontested fact, in relation to folio 108 of the clinical file of the San Juan de Dios Hospital, in its volume I, and 120 of the clinical file of the INS, in its volume I, as well as 65 and 36 of the evidentiary file of the INS, as well as 10 of the precautionary measure file, 85, 86, and 78 of the main file). In that nosocomio the plaintiff was attended, given primary care, and stabilized, to then be referred to the INS, exclusively based on the institutional knowledge that he was covered by a compulsory automobile insurance policy. (Uncontested fact, in relation to the testimony given in a supplementary hearing by doctor Javier Francisco Soto Fallas). Regardless of whether that was appropriate or not, it was an uncontested fact, which is also supported by the evidence on folio 75 of the file identified as INS evidence. Well then, effectively the plaintiff was protected by a policy of that type, but it would have been up to his discretion to remain in that medical center in order to receive medical attention -San Juan de Dios Hospital- or be transferred, as the case may be, to the INS, given that the application of the aforementioned policy not only corresponds to a right that exclusively pertains to him and is waivable, but also that, at the time he suffered the traffic accident, he was directly insured by his employer as a salaried worker before the CCSS. (Uncontested fact, in relation to folio 11 of the precautionary measure file containing a copy of the valid employer order for the month of the accident, as well as folio 79 of the main file containing a copy of the card accrediting him as a direct insured). Regardless of whether or not it is clear that the plaintiff was insured by the INS, the plaintiff was insured at the time by the CCSS, on this matter what is established in Article 23 of the Regulation on Compulsory Automobile Insurance is consistent, which reads as follows in the relevant part: <i>“The healthcare benefits established by this insurance shall begin to be provided by the doctors of the National Insurance Institute or those designated by it, or, the victim may contract them in their capacity as injured, but in the latter case the cost of the healthcare benefits that said Institute will recognize shall be subject, in order, to the rates in force for similar services provided by the Institute, or failing that, those of the Costa Rican Social Security Fund, and lastly, those defined in agreements signed between the Institute and private individuals, without prejudice that the professional or the victims, if applicable, could charge the difference to the person responsible for the accident”. </i>That is, the person insured by the INS in any case retains the right to choose by whom to be treated, which does not exclude the application of their policy, so that it could not be affirmed under the non-legal principle that whoever can do more can do less, that they could not choose to be attended by the CCSS, whether under the compulsory automobile insurance or simply by virtue of being insured before said institution providing health services. In this line of thought, note that doctor Javier Francisco Soto Fallas, a specialist at the San Juan de Dios Hospital, reported at trial that when a patient with injuries caused by a traffic accident is admitted, what is usually done is to ask them if they are covered by a compulsory automobile insurance policy or not, so that if they indicate yes, they are referred to the INS, apparently automatically. It must be added that no evidence exists in the administrative files that the plaintiff was informed of his rights in this regard, nor that his referral to the INS corresponded to his will, although this aspect is not central to the resolution of this matter to the extent that it is also not recorded or stated by him that action was taken against his will. Well then, having been referred to the INS by the medical authorities of the San Juan de Dios Hospital, the plaintiff entered that state enterprise (INS Health) on March 9, 2012, where he was admitted and given care. On March 12, 2012, he was evaluated in the orthopedics service by the doctor identified as Max Rojas Badilla, (a witness from whom, having been admitted as evidence in this case, the representation of the INS desisted at the trial hearing) who would have diagnosed the presence of a transcervical fracture in the neck of the left femur of the left hip, requiring surgery, for which, in a first line of thought, removal of an element associated with a previous osteosynthesis existing in the femur had to be performed, both operations having to be carried out at the same time. (This is visibly recorded on folios 85 and 86 of the main file). Already at the INS, on March 17, 2012, and as part of the service provided to the plaintiff, he was transferred to La Católica Hospital where that surgical intervention was performed on him by the same doctor Max Rojas Carranza. This, in addition to being an uncontested fact, is recorded on folios 39 and 40 of the INS evidentiary file. Two days later, on March 19, 2012, the plaintiff had been transferred back to the INS, where its medical staff reported that due to his obesity a better reduction was not possible, with a risk of necrosis or pseudoarthrosis of the hip. (This is extracted from the review of folios 12 of the main file, in relation to 84 and 109 of the precautionary measure file, and the testimony in the supplementary hearing by doctor Javier Francisco Soto Fallas, who explained the surgical procedure performed at trial). Then, on March 21, 2012, the plaintiff was transferred by the medical authorities of the INS to his home. (Uncontested fact in view of the statements of the INS representation in its writ of response to the claim). By March 27, 2012, the coverage amount of the compulsory automobile insurance policy under which Mr. Gilberto Badilla Castro was being treated at the INS had been exhausted, according to evidence on folio 15 of the precautionary measure file, and it would later explain the conduct adopted by that state enterprise. Prior to that, on April 9, 2012, the plaintiff had moved to the INS, where, as doctor Max Rojas Carranza was not present, he was attended by doctor Javier Castro Figuls, who indicated that he presented the hip with three screws with some "varo"</span><span lang=EN style='font-size:11.0pt;line-height:150%;font-family:ArialUnicode;mso-ansi-language: EN'>”</span><span lang=EN style='font-size:11.0pt;line-height:150%;font-family: Arial;mso-ansi-language:EN'>, that is, "curvature," and diagnosed that <b>in the surgery performed there was damage to the hip</b>, proceeded to remove the "avión"</span><span lang=EN style='font-family:ArialUnicode;mso-ansi-language: EN'> </span><span lang=EN style='font-size:11.0pt;line-height:150%;font-family: Arial;mso-ansi-language:EN'>which is the device used to prevent rotation of the hip that had been placed after the surgery, and scheduled an appointment for the following April 23, and finally, he was again sent home. (This is a fact deemed proven as it was not contested in view of the statements of the INS representation in the writ of response to the claim, since, as outlined in the writ of claim, it was not rejected in that regard). The plaintiff had been scheduled for an appointment that was to be understood as a check-up, however, prior to that, on April 12, 2012, he appeared at the INS again, where doctor Max Rojas Carranza -who had treated him previously- limited himself to reviewing the insurance policy under which he was given care, proceeded to write a discharge summary and proceeded to transfer the plaintiff to the Costa Rican Social Security Fund based on the fact that the coverage amount of that policy had been exhausted, -which we said had occurred on March 27, 2012, with an indication in the referral <b>that it was to the orthopedics service and <u>with character of urgency</u> </b>. (This fact was one about which there was no controversy as it was not rejected by the INS representation in its writ of response to the claim, which is also supported by folio 189 of the INS clinical file, where the corresponding medical notes report is recorded). That was the state of things on April 17, 2012, the same day in which, having indicated to the plaintiff that he would no longer be attended at the INS based on what was stated, he was received at the San Juan de Dios Hospital according to the indicated medical referral, where he was evaluated by doctor Daniel Martínez Castrido, who indicated <b>that there had been a failure in one of the procedures performed</b>, specifically the osteosynthesis, presenting migrated screws, displaced Cabella and neck, and that this corresponded to a complication of the surgery performed by the doctor from the INS, for which, considering that this circumstance excluded the responsibility for care of the Costa Rican Social Security Fund, <b>the patient had to be given a counter-referral to the INS</b>. Thus, he was discharged from the San Juan de Dios Hospital that same day, April 17, 2012, the referred failure in the procedure carried out at the INS consisting of the bone and/or its fragments, despite the osteosynthesis performed, not being aligned in a manner conducive to the consolidation of the fracture. (Uncontested fact, in view of the statements of the CCSS representation in its writ of response to the claim, in association with folio 20 of the precautionary measure file and the trial testimony of doctor Javier Francisco Soto Fallas, who properly explained the matter at trial regarding the patient's condition at that time and what had been recorded concerning the failure in the related procedure). In this way, from the San Juan de Dios Hospital, a counter-referral was issued that same day, April 17, 2012, for him to be attended at the INS. On this matter, doctor Javier Francisco Soto Fallas explained with certainty and propriety at trial that for having acted in the manner described, medical reasons would have been involved in what is most relevant. While it is irrelevant for the resolution of this matter whether or not there was medical malpractice on the part of the INS medical staff, particularly the doctor who surgically intervened the plaintiff, Mr. Max Rojas Carranza, witness Javier Soto Fallas reported that despite the INS having performed a procedure on the plaintiff known as osteosynthesis, through which the aim is to relocate the fractured bone in a position such that its consolidation is achieved by placing, among other elements, screws or plates, the fact of the matter is that upon receiving the patient it was observed that the bone was displaced and, in that understanding, the screws intended to achieve the opposite were poorly implanted, so that on two levels, what was appropriate from the medical point of view first was that, dealing with eventual complications presented in the procedure, it should be the same doctor who performed the intervention who again observed the plaintiff, determining what complications arose in the specific case, as well as the necessary corrections that should be applied to alleviate the health problem in the patient. Furthermore, in response to questions asked by the Tribunal, he explained that there was also a deontological, if not ethical, issue that imposed on the treating doctor at the INS the duty to return to the evaluation and correction of the patient's situation, if from his actions the problems that Mr. Badilla suffered -the fracture- could not be alleviated, this being associated with the duties that prevail in the exercise of the medical profession as this Tribunal understands it. That being the situation, it was Mrs. Mayra Torres Tapia who went to the INS to implore insistently -as she assured clearly in her deposition as a witness at trial without there being any reason to doubt the veracity of her statement- that Mr. Gilberto Badilla Castro be given attention given that he would not receive it at the San Juan de Dios Hospital according to the said counter-referral, a request that was rejected exclusively based on the fact that the policy coverage had been exhausted, referring him again to the CCSS, with a referral and discharge summary, but without the patient being evaluated again. (This corresponds to a fact uncontested in part, in view of the statements of the INS representation in its writ of response to the claim which does not reject that circumstance, in relation to the declaration of Mrs. Mayra Torres Tapia in the supplementary trial hearing). Given the foregoing, on April 20, 2012, Mr. Gilberto Badilla Castro presented himself at the San Juan de Dios Hospital, where without being evaluated again and for the same reasons for which he had been referred to the INS, the CCSS medical staff insisted that he should be attended at the INS, nonetheless, he was given a check-up appointment for April 26, 2012 -there being no doubt that the position continued to be that the INS should be the one to treat Mr. Badilla. (Uncontested fact, in view of the statements of the CCSS representation in its writ of response to the claim). Doctor Javier Francisco Soto Fallas was clear that the referred appointment was to decide how to act depending on the treatment given to the plaintiff at the INS, and whether or not he was attended, and how. With all this, on the day his check-up appointment was scheduled, namely April 26, 2012, the plaintiff was received at the San Juan de Dios Hospital, where that same day it was recorded -again- by a note from the treating doctor Javier Francisco Soto Fallas, in which he recorded the following: <i>“Patient referred from INS due to exhaustion of policy. However, today presents with history of left femur fracture at hip level with transcervical trace, surgery was performed at the INS on 3/17/2012 with failure in the osteosynthesis, presents with migrated screws and displaced head and neck. At this time it is not considered an emergency to operate on him and from a medical-legal point of view it is a complication of the surgery performed by the INS doctor, who must assume it clinically with limitation to hip flexion due to its displacement “</i>, meaning, that applying a surgical procedure to the patient through which external devices such as screws, plates, nails, etc., are placed to align and/or join the bone or its fragments in order to promote the consolidation of the fracture, through the formation of bony bridges and newly formed or new blood vessels that in both cases allow the passage of the inputs that the bone uses to consolidate, this had not been achieved. The plaintiff was transferred to his home, an operation not being considered an emergency even in that state, it being further considered and in the main that the condition he presented was associated with or was a product of the osteosynthesis procedure that was applied to him by the INS without a positive result. (Folio 116 of the clinical file of the San Juan de Dios Hospital, in its volume I, in relation to folio 34 of the same file in its volume II, the statements of the CCSS representation in its writ of response to the claim, and the trial testimony by doctor Javier Francisco Soto Fallas). The failure in the procedure had already been detected by the medical staff of the INS, as stated above, since April 17, 2012, when a complication associated with the patient's obesity was mentioned. Meanwhile, neither at the San Juan de Dios Hospital nor at the INS was the plaintiff found to be treated towards correcting his hip fracture. Finally, the plaintiff resorted to this Jurisdiction in a pre-action precautionary measure, as a result of which, on May 30, 2012, the order identified with number 266-2012 was issued within this case, under which it was exclusively ordered to the CCSS <i>“...</i></span><span lang=EN style='font-size:11.0pt; line-height:150%;font-family:ArialUnicode;mso-ansi-language:EN'> </span><i><span lang=EN style='font-size:11.0pt;line-height:150%;font-family:Arial;mso-ansi-language: EN'>to medically attend Mr. Gilberto Enrique Badilla Castro in an integral manner regarding any affectation to his health that he may be suffering, whether by virtue of the consequences of the traffic accident he suffered, or of the surgical operations and/or treatments that may or may not have been practiced by third parties without any distinction whatsoever”. </span></i><span lang=EN style='font-size:11.0pt;line-height:150%;font-family:Arial;mso-ansi-language: EN'>(See folios 88 to 96 of the precautionary measure file). Whether or not the plaintiff had been given an appointment by that medical center previously for a date before or after the adoption of the precautionary measure, it is correct to state that it was not to perform any procedure that, as will be seen, was necessary to correct the fracture he presented in his hip, but rather, and having heard the trial declarations of doctor Soto Fallas, it was to decide what to do depending on what the INS did on its own, this, despite the fact that, having been rejected for attention at the INS, the plaintiff had also been rejected at the San Juan de Dios Hospital on two occasions with knowledge of that circumstance, while the fracture he presented was not consolidating due to the result of the procedure performed at the INS, or in its case due to complications inherent to the plaintiff's physical circumstances -which, we insist, is irrelevant, to the extent that the plaintiff was not being attended in any way to directly correct his affliction-. Thus, it was by virtue of what was ordered in the precautionary measure that on May 31 the plaintiff was received again at the San Juan de Dios Hospital (uncontested fact in part, in association with the declarations of Mrs. Mayra Torres Tapia), at which point the rigorous preparatory tests were performed, and it was determined necessary to alleviate his condition -the fracture- to perform a surgical intervention, which was successfully performed on June 25, 2012. Nothing allows us to affirm that this could not have been determined weeks earlier. In that operation, a total hip replacement was performed on Mr. Badilla, but not before removing three cannulated screws placed by the INS in its time, as is clearly inferred, and prior to the intervention it had been verified that the plaintiff presented death or disappearance of bone material. (Folios 02 to 24 of the clinical file of the San Juan de Dios Hospital, in its volume I, in relation to the trial testimony of doctor Javier Francisco Soto Fallas, folio 84 of the precautionary measure file, and folios 21 and 22 of the main file). Doctor Javier Francisco Soto Fallas explained at trial that the normal or usual procedure for a hip fracture is to admit the patient and surgically intervene, to adopt the necessary actions, either to ensure the fracture consolidates adequately, or to replace the hip. On the other hand, he also explained that the procedure identified as osteosynthesis that was performed on Mr. Gilberto Badilla Castro at La Católica Hospital at the request of the INS, was performed with a failure that, if it did not delay, prevented the consolidation of the hip fracture he presented. (The trial testimony of doctor Javier Francisco Soto Fallas). It must be emphasized that whether or not the plaintiff was insured by the INS, at the time he suffered the traffic accident and was attended in both nosocomios, he was insured by his employer as a salaried employee before the Costa Rican Social Security Fund, he worked as a private security officer, and he was in a common-law union with the person identified as Mayra Torres Tapia, the latter being the one who took charge of giving care to the plaintiff during his convalescence, insofar as it occurred in his home. (Uncontested fact, in relation to the declarations both of the plaintiff in his writ of claim and at trial by Mrs. Mayra Torres Tapia, and folio 11 of the precautionary measure file, 79 of the main file). It was also deemed accredited that from April 17 to May 31, 2012, neither at the CCSS nor at the INS did their staff consider themselves responsible for giving direct and principal treatment to the plaintiff aimed at correcting his condition -the fracture-.

(Undisputed fact) **5.2.-** It is concluded from the foregoing that the CCSS, through the service provided to the plaintiff at the Hospital San Juan de Dios by its staff, engaged in abnormal conduct in the provision of medical services, which constitutes conduct misaligned with the legal system and grounds for imputation of patrimonial liability, in a causal link exclusively in relation to the subjective non-material damages claimed by the plaintiff, but partially, as stated above and from the moment it denied one of its insureds the medical attention that it is ultimately known he required, under the argument that this corresponded to the INS. It cannot be left unsaid that regardless of whether the reasons that, from the perspective of the Hospital San Juan de Dios staff, led them to refer the patient to the INS were correct or not, the truth is that once his attention was rejected at that Institute, they were obliged to attend to him without any delay, or, if applicable, to inquire with the INS about its reasons in order to immediately proceed to define what to do with the plaintiff. There is no relevance for the purposes of the CCSS in analyzing the scope of mandatory motor vehicle insurance when, in any case, the plaintiff was a direct insured as an employee under the system administered by this sued Public Administration. Thus, the medical authorities of the Hospital San Juan de Dios should have noted that regardless of whether the patient presented a problem associated with a failure in the procedure performed by the INS, and that in their judgment, whether for medical reasons or civil liability reasons, it was the INS's responsibility to correct the problem, the truth is that it was the plaintiff's prerogative to decide whether he wished to be treated by the CCSS or not. Even though his opinion was apparently taken on the matter, note that by April 17, 2012, it was at least known—or at least should have been known by the medical staff of the Hospital San Juan de Dios—that the plaintiff had been referred by the INS on the grounds that his policy had been exhausted, which could have anticipated something about the fate that Mr. Badilla would face when presenting himself before that insurance company. Thus, prior to re-referring the plaintiff to the INS for attention under his policy and/or, if applicable, for corresponding to a medical duty imposed by medical reasons and/or deontological principles, the truth is that the patient's eventual rejection was a totally expectable or at least possible outcome—as indeed it was. It does not imply that it was not the CCSS's duty to attend to the ailment the patient was suffering efficiently and directly, without prejudice to what was done by the INS medical staff, the plaintiff being a direct insured of the system administered by the CCSS, and at the very least, if it was deemed that his attention should be provided by the INS, having received the plaintiff after his attention was rejected by the INS—this circumstance being known—the least that could be expected was that prior to re-referring the patient, they would verify with the INS whether he would be attended to or not beforehand, instead of leaving the patient to his fate, as was illegitimately done. Access to health services for an insured person like the plaintiff cannot be conditioned or left to a third party without certainty that he will be attended to. In the plaintiff's case, added to the above is the fact that, according to the trial testimony of Dr. Javier Francisco Soto Fallas, the normal procedure for a hip fracture case is surgical intervention, through which to correct the bone's position—for which the implant of screws or plates can be used—with the purpose of placing the bone structure in a position that seeks adequate consolidation of the fracture. Furthermore, his testimony was in agreement with that rendered by Mrs. Mayra Torres Tapia; two days after this intervention is performed, it is expectable that the patient can even take steps. Contrary to this, improperly, the plaintiff was forced, given the conflict between both institutions over the responsibility for performing this procedure—which was in any case necessary for the plaintiff according to the actions of the CCSS as of May 31, 2012—to wait, even indefinitely while the dispute continued, until it was only due to the precautionary intervention by judicial order issued against the CCSS that the plaintiff was given the due attention. From the above, it follows that the plaintiff indeed suffered neglect in terms of the provision of health services that should have been timely provided, and this circumstance persisted at least from April 17 to May 31, 2012, as the plaintiff reproached and according to the cause of action expressed in his complaint, as a consequence of which, administrative conduct occurred on the part of the CCSS medical staff adopted in misalignment with the legal system, which corresponds to abnormal conduct in service provision matters, from which, as will be seen, a damage emerged that must be compensated to the plaintiff as he is not obliged to bear it, and there being no cause that breaks that causal link that must exist according to the doctrine that informs the provisions of Article 41 of the Constitution and Article 190 of the General Law of Public Administration.- **5.3.-** From the systematic analysis of the evidence in this regard, it follows principally from the testimony of Mrs. Mayra Torres Tapia in the supplementary trial hearing, in association with the rules of experience, that the plaintiff's desire between April 17 and May 31, 2012, was to find relief from the intense pain he suffered, as well as to free himself from his disabling condition that prevented him from moving by himself, aggravated by his obesity and generated by the existence of a fracture in his hip resulting from a traffic accident. During that period of time, the two sued institutions, initially called upon to solve the corresponding part of his situation, denied him attention for various reasons. Setting aside the considerations that will be made regarding the INS, it is clear that the plaintiff was not only aware of his right to be attended to by the CCSS by virtue of being a direct insured as an employee, but also of the injustice that the denial of service represented. Moreover, Mrs. Mayra Torres Tapia's testimony was clear and credible insofar as it described the physical and emotional state of the plaintiff during that period of time, same within which his economic conditions, among other things, prevented him from providing conditions for his care, or at least so that his wait could be as comfortable as possible. In fact, she described how the plaintiff had to remain for hours and days without anyone assisting him at home from the early hours of the morning until night, and she extensively described the precarious economic situations they experienced. She was also emphatic in informing this Court how she personally witnessed that the plaintiff experienced great pain, as well as feelings that this Chamber cannot fail to describe on its own account, such as impotence, anguish, unease, frustration, anger, sadness, desperation, negative alterations in his character and ability to interact with the person who was caring for him as best she could—his common-law partner, Mrs. Mayra Torres Tapia—even a desire not to live, all due to the fact that neither at the CCSS nor at the INS did their staff consider themselves responsible for providing him direct treatment aimed at correcting the state he was in, while he experienced intense pain and serious difficulties in attending to his most basic needs, given that, among other things, he was unable to fend for himself. The simplest rules of logic associated with experience, as well as the testimony of Dr. Soto Fallas, in which he agreed that a situation like the plaintiff's produces pain, to which, of course, each person has a greater capacity for tolerance, demonstrate that if the plaintiff had to fend for himself during that period of time, just as Mrs. Torres Tapia described when she could not look after him while she worked from seven in the morning to eight at night, he undoubtedly had to experience great pain to attend to his simplest needs—to which is added that the input previously placed to prevent the mobility of his hip had been removed. The described feelings, associated with the fact that he was aware that his right to health was being violated, undoubtedly would have caused a strong feeling of frustration and anxiety in any person. All in all, this Court estimates that the applicable liability shall not be joint and several, because the imputation criterion is very different from that applicable to the INS's case as will be seen, and also because we estimate that the sum claimed is not in accordance with the intensity with which the plaintiff experienced the harmful effects described. The legal nature of this entity and the service it provides through the hospitals it administers, we consider, imposes a greater reproach of responsibility compared to that which can be attributed to the INS, which provides services of a private nature. Thus, we estimate it reasonable and adequate to the merit of the circumstances the plaintiff went through to award the sum of fifteen million colones as subjective non-material damages, which must be paid by the CCSS in favor of Mr. Badilla Castro once this judgment is final, as is hereby ordered.- **6.- On the partial merits of the claim against the Instituto Nacional de Seguros.** With respect to the Instituto Nacional de Seguros, this Chamber is of the opinion that the denial of attention to the plaintiff once his insurance policy was exhausted regarding the amount of its coverage, although it initially conformed to what is dictated by the Law of Transit on Public Land Routes, cannot be considered conduct in accordance with the law if the legal system is applied in its entirety to the specific case, but in the matter of the provision of medical services through the operation of a hospital center. This Court is of the opinion that a separation must be made here between what constitutes a provision of services under the content and scope of an insurance contract and what corresponds to the obligations imposed by the legal system in a matter different from that, which is the provision of services such as those provided to the plaintiff once he was accepted as a patient at the Hospital administered by the INS. On this particular topic, the existing regulation is directly applicable to the INS to the extent that it attends to a patient in its hospital center, in what comprises constitutional and international law, which establish as a fundamental and human right the right and access to health services, which must at all times be comprehensive and must place at the pinnacle of any institutional interest the well-being, also comprehensive, of the treated subject. We must start from the proven fact that the opinion of the CCSS doctors upon receiving the plaintiff after surgery was performed on him at the INS was that he presented a failure derived from the procedure that was performed on him, which prevented the consolidation of the fracture in his hip, such that it was their opinion, even for medical reasons, that he should be attended to by the same doctor who performed that failed procedure. The core issue is to determine whether the INS's actions in applying what it understands are the scopes of the mandatory motor vehicle insurance have the power to exclude its liability. The answer is negative in this Chamber's opinion. We must insist that whether an insurance contract is involved or not, upon a patient being received by the INS and medical treatment being given to him on its account, it is simultaneously governed by the regulations that govern in the matter of the provision of medical services, the operation of hospitals, the duties and rights of the users of these services, and in what corresponds, both by the General Regulation of the National Health System and the Code of Medical Ethics that governs the professional practice of the staff who treated the plaintiff directly and/or from their position as hospital medical authorities. We will begin by saying that after the surgery performed on the plaintiff, his referral to the CCSS on the grounds that his policy was exhausted is not, by itself, a circumstance for which the company should be held liable. A different thing occurs after the plaintiff is denied attention and the way in which actions were taken in this regard, starting from the moment he is re-referred by the Hospital San Juan de Dios. First, this not having been denied by the INS's representation, through Mrs. Mayra Torres Tapia, the INS was implored for attention for the plaintiff on the occasion that the CCSS was denying him service and he was experiencing great pain. The INS's refusal to receive the plaintiff again, based exclusively on the exhaustion of his policy, is not admissible, as the duty of its medical staff was to have inquired about the reasons why the Hospital San Juan de Dios was referring him back. This was completely omitted in the face of the steps taken on the plaintiff's behalf by Mrs. Mayra Torres Tapia, being duly authorized to do so. The plaintiff presented a failure in the medical procedure performed by the INS according to the CCSS's criteria, so its staff had the responsibility to at least verify whether this was so or not, to then decide—whether costs were generated or not—how to proceed with the patient who was already known and was not being accepted by the CCSS. Contrary to this, it decided simply not to evaluate the plaintiff's case and left him to his fate, knowing that he would not be attended to at the Hospital San Juan de Dios. Minimum diligence in the face of the plaintiff's situation would have been, prior to denying him attention, to verify with the Hospital San Juan de Dios staff whether he would be received back or not. The re-referral to the INS was made—rightly or wrongly and among others—based on medical, even deontological reasons, as stated by the Hospital San Juan de Dios doctor, Dr. Javier Francisco Soto Fallas, so the denial of attention by the INS would have been expected to be based on reasons of the same nature, and not contractual ones depending on the scope of an insurance contract, because in its activity, the provision of health services merges with that of operator in the insurance market, without this latter activity excluding the regulations governing the operation of a hospital. Within the framework of the provision of hospital services, it is worth noting that Executive Decree No. 19276, of November 9, 1989, General Regulation of the National Health System, provides that the INS, together with the CCSS and the rest of the public and private institutions indicated therein, form part of said system, and must act in an articulated manner, that is, systematically and coordinately. Article 9 states that: *"In order to guarantee comprehensive health care for the entire population, the right of all citizens to receive health services is recognized in the facilities of the Ministry of Health, the Costa Rican Social Security Fund, and the Instituto Nacional de Seguros; therefore, the provision of comprehensive health services may not be denied to any particular person, without prejudice to subsequent verifications and corresponding charges when applicable."* A member of the system, according to Article 11, is the INS, which is conceived as a: *"... institution that helps to broadly and socially beneficially reduce the economic uncertainty that members of the community face individually and collectively. Its role is to help prevent workplace and traffic misfortunes and to provide the injured with medical, hospital, and rehabilitative services* **in a comprehensive manner** *."* (The highlighting is not from the original). Meanwhile, Article 13 reads as follows: *"Health establishments shall be articulated among themselves in service supply networks according to levels of care, capable of offering universal coverage with services at the first level of care and staggered access to levels of greater complexity, as appropriate to the user's need."* For this Court, it is clear that at the moment the re-referral was made from the Hospital San Juan de Dios to the INS, as subsequently occurred as of May 31, 2012, what the plaintiff required was a surgical intervention to correct his hip fracture, even with the procedure performed by the INS or as a consequence of it, this due, among others, to medical reasons, the ideal being that he be treated by the same physician who performed the procedure that failed for the consolidation of the hip fracture, being the professional best placed to determine what complications had arisen in the patient. Finally, according to Article 42 of the same regulatory body: *"The* **basic** *functions of Hospitals are the following: (...) 3) Coordinate activities with centers of greater and lesser complexity in the health services network and with committees that represent the communities."* Thus, it is determined that a duty of coordination exists, in any case imposed on the INS, not to leave one of its patients to his fate upon a referral to another medical center, especially under the plaintiff's circumstances and, moreover, on the occasion of being re-referred for medical and liability reasons in that sense. From an ethical—if not deontological—point of view, the Code of Medical Ethics, Executive Decree No. 35332 of May 15, 2009, imposes on the professional in its Article 22 that: *"...* **must not abandon his responsibilities toward his patient** *, even temporarily,* **without leaving another trained and informed physician to substitute him in the attention of the former** * , except for a fully demonstrated force majeure reason."* This speaks of the possibility of being relieved from the attention of a patient, to transfer him to another professional. This is applicable to the specific case, because the plaintiff is referred to a medical center that refers him back for medical reasons about which no inquiry was made, and then rejects his attention, it is insisted, not for medical reasons, but contractual ones of a nature different from the science at hand. In any case, Article 34: *"Independently of where the exercise of the profession is carried out, the interests and integrity of the patient must be respected."* Article 36: *"The physician, from the moment he has been called to give his care to a sick person and has accepted, is obliged to ensure him, immediately, all medical care in his power, personally, or with the help of qualified third parties."* Article 42: *"The physician must provide all pertinent information to the patient at the time of transferring him for purposes of* **continuity of treatment** *, upon ending the physician-patient relationship, or if the patient requests it."* (The highlighting is not from the original). Finally, Article 63: *"The relationships of the physician* **with other professionals and support staff in the health area** * must be based on mutual respect, on the professional or labor freedom and independence of each one,* **always seeking common interests for the patient's well-being** *."* (The highlighting is not from the original). In this way, the legal system imposes not being indifferent to a re-referral such as that given to the plaintiff by the Hospital San Juan de Dios, regardless of whether its medical staff's criteria are correct or not. At the very least, the plaintiff should have been attended to in order to evaluate him and thereby determine whether or not it was the INS's responsibility to correct a treatment or procedure poorly executed in its entirety and for which it was responsible to the patient, a case in which, should the INS be found liable, whether his policy was exhausted or not, there is no doubt that the duty to correct the patient's problem prevails if he so requires or claims, at no cost for reasons of medical liability, as warned by the CCSS doctors. This Court observes that with the actions taken, Law No. 8239 on the Rights and Duties of Users of Public and Private Health Services, Article 2, subsection e), was also disregarded, which provides as a right of these users the right to receive attention efficiently and diligently. Article 50 of the General Health Law states that: *"Professionals or persons authorized to practice in health sciences, responsible, by reason of their profession, for the technical or scientific direction of any medical care establishment, pharmacy, and similar establishments, shall be jointly and severally liable with the owner of said establishment for the legal or regulatory infractions that are committed in said establishment,"* which reinforces to some degree what was performed in the aforementioned terms by the medical professionals who re-referred the plaintiff from the Hospital San Juan de Dios to the INS, and correlatively would have imposed on the Institute the duty to at least evaluate the plaintiff to determine his fate. It is another matter, as noted, that the CCSS, knowing the INS's position, insisted on its position to the detriment of the affected party's interests. It should have been taken into account, according to the testimony of Dr. Javier Francisco Soto Fallas, that it is rationally acceptable that the suitable professional to determine the plaintiff's health conditions and the treatment to be followed is the treating physician, in this case, the one who performed the procedure, for being the one who best knows what he did, to establish from there what the health services to which the system user is entitled should be, based on a relationship that should exist between the scientific knowledge that the professional possesses and the patient's clinical history. We understand from this perspective that an entity that is a member of the National Health System, in this case the INS, cannot deny a medical service under the circumstances in which the plaintiff found himself, alleging exclusively that policy coverage no longer exists, or that it is not included in its benefits plan, when, on the contrary, in cases such as the present one, it is the entity's duty to have all the elements that from a medical point of view are necessary to adequately substantiate the decision to authorize or not the service to the patient, something it did not do. We add to the above that even in the matter at hand, a liable party is one who has the legal duty to repair a damage, even if they did not cause it directly or materially, which is fully applicable to cases of medical liability to the extent that it supposes, among other aspects, the obligation that physicians have to repair and satisfy the consequences of acts, omissions, and voluntary and even involuntary errors, within certain limits, of course, contained in the exercise of their profession. In insurance matters regarding the INS, we also have that insurance unfolds, being able on the one hand to tend to repair the damage caused and nothing more, or, in its case, to take charge of the treatment of the patient or user; here the application of regulations different from those governing the insurance market and its products supervenes. In the case of medical activity, all those directly or indirectly involved in the occurrence of the damage are liable, such as the physician, the clinic or hospital, the auxiliaries, and the insurers, so a medical center could not find protection in the argument that, as a business organization, the same deontological rules that govern its professionals are not applicable to it. Having said the foregoing, it is the opinion of this Court that although the legal system might not have imposed on the INS the duty to correct the failures of the procedure it performed on the plaintiff, it did impose the duty to rule out its liability in light of the information contained in the re-referral given to the plaintiff by the doctors of the Hospital San Juan de Dios, which imposed on it the obligation to at least have evaluated him.

With cause in its actions and as was the reality, the plaintiff's situation, in that he did not receive attention in either of the two hospitals, was unjustifiably prolonged as a barrier to accessing the health services to which he was entitled in a timely manner, in the face of a condition that has the potential to affect the quality of life of any person due to how incapacitating the injury suffered was, as well as painful, thereby the INS, through its conduct, contributed to the non-material damage (daño moral) claimed liability to be imputed to it, albeit in a more autonomous manner as it was in the case of the CCSS and due to different causes as we have set forth, it not being acceptable that exclusively under the protection of the Ley de Tránsito and the coverage of the plaintiff's insurance, it was found legitimized to have acted in the way it did. The conduct thus displayed constitutes an anomalous one in the matter of health service provisions, which generated damage of the same subjective non-material kind (daño moral subjetivo) for which liability was found against the CCSS, but, given the participation in the facts by this state enterprise, it is considered that the reproach or imputation to be made to the INS is lesser, for which it is considered that the subjective non-material damage should be compensated in a sum of five million colones and it is so ordered accordingly, based on considering that amount adequate. As a separate note, this Court cannot miss the opportunity to refer to an aspect regarding the attention that was given to the plaintiff, which it is considered must be reviewed by the medical authorities of the INS. We consider that the patient must be informed adequately and with the precision possible given his condition and the projection of the care he will receive from the medical personnel of the INS, at what moment his policy will be exhausted and what the consequences of that will be, so that he has the opportunity to decide in an informed manner if it will be in another care center that he will prefer to be treated. It is not observed that this is occurring currently, at least from the case under study, so the defendant Institute is urged to take note of this observation for present and future occasions.- **7.- On the impropriety of the petitionary items for compensation due to the alleged lack of disability subsidy (subsidio de incapacidad), and for expenses associated with the purchase of medications.** In a manner that is inherently confusing, the plaintiff party petitioned the following by way of a claim for damages and/or losses against both defendant entities jointly and severally: "*1. For the damage caused by the forty-five days without attention to my health, in which I found myself completely deprived of medical assistance and the lack of subsidy and disability during that time for an amount of six hundred seventy-two thousand four hundred thirty-three colones and sixty-five céntimos*". From the damages petitioned, barely is it possible to identify that constituted by the lack of disability subsidy and medical leave (incapacidad) —we must understand— that he would have suffered during the time within which he would not have been attended by any of the defendant parties, as both refused to provide attention to the patient. Thus, insofar as the damage is not identified, no analysis shall be carried out in this regard, this court not being mandated to speculate when it instead corresponds to the party to be clear in what it petitions. On the other hand, regarding the subsidy and disability vaguely enunciated, as well as the claim for medical expenses to be paid according to invoices, the majority of which do not identify the purchaser of various pharmaceutical products, it suffices to state that the claim is declared without merit, on the basis that it was not proven by the claimant that, having required the supply of medications from the CCSS within the period of time that elapsed from April 17 to May 31, both of 2012, they were denied to him, nor that, in the same manner, he was denied disability leaves or the delivery of the respective subsidy, all in the absence of elements of conviction that allow affirming the contrary. Furthermore, although mistreatment of the plaintiff was spoken of at the Hospital San Juan de Dios by its personnel, it is not found within that sought that any recognition, moreover, is being claimed for that supposed reproach, so no analysis shall be made in that regard.- **VIII.- Corollary.** The plaintiff only partially proved the elements that, in accordance with the legal system, make admissible the claims of liability formulated against the defendant entities in the terms set forth in this judgment. In what was not, it is therefore imposed to declare the claim without merit, that is, regarding the alleged damage identified or associated with the absence of disability subsidy and medical leave, as well as the payment for expenses —invoices— which he claimed to have incurred due to the conduct displayed by the defendants. In what was admissible, given that both defendant entities illegitimately affected the plaintiff's right to health and access to medical services, in an autonomous manner each is condemned, the Caja Costarricense del Seguro Social, to pay the sum of fifteen million colones and the Instituto Nacional de Seguros to pay five million colones, in both cases as compensation for the non-material damage caused, all from the finality of this judgment.-” In observance of the foregoing, the liability of the public servant to third parties lies within the scope of the subjective liability regime, consequently requiring, for all purposes of determining the existence of fault (culpa) or willful misconduct (dolo) in the mind of the Administration's servant or agent, without prejudice to the other elements that must concur, such as the existence of the damage and the causal link between that damage and the conduct carried out, for the reproach of imputation of liability to operate. On the other hand, the objective liability regime of the Public Administration, unlike what occurs with subjective liability, arises without the need to demonstrate the willful misconduct or fault of the agent causing the damage, it being sufficient to prove, however, the existence of the "risk" to generate it, which is why the notions of unlawfulness and culpability do not apply, and therefore, the principle of reversal of the burden of proof in favor of the injured party applies. For these purposes, the alleged Public Administration causing the claimed damages must compensate them if its conduct effectively and efficiently generated them, unless it demonstrates some exonerating cause, without prejudice to the unavoidable condition, indeed reiterated, that the damaging effect constitutes the cause of the deployment of its activity. Thus, the concurrence of four elements is required, namely: a) An injury (lesión), which consists of unlawful pecuniary damages, because the person suffering them has no duty to bear them; b) An administrative conduct (conducta administrativa) to which the production of the alleged damage is linked; c) A causal link (nexo causal), formed by the existence of a direct cause-and-effect relationship between the act (administrative conduct) being imputed and the damage produced; and d) That none of the justifying causes to which we referred earlier exist, since their existence can legally disconnect the harm produced from the conduct of the Public Administration, such that the damaging effect cannot be imputed to it, breaking the causal link (nexo de causalidad) upon the occurrence of an exempting situation such as force majeure (fuerza mayor), the fault of the victim (culpa de la víctima), and the act of a third party (hecho de un tercero). The regime of patrimonial liability of the State and its institutions provided for in Articles 9 and 41 of the Political Constitution, and 190 et seq. of the General Law of Public Administration, is then essentially objective in nature, so for it to arise, it suffices that there exists an indemnifiable damage, an administrative conduct, and a causal link between the two. It must be kept in mind that it is under this type of objective criterion that it becomes possible to attribute liability to the Public Administration, unlike what occurs with its public servants, for whom a subjective attribution criterion must also be used. Furthermore, having determined the criteria under which it is appropriate to establish the liability of the Public Administration and/or its agents or public servants, we are interested in pointing out that at the same time, there is a difference regarding the imputation criteria that operate for establishing or determining said liability in the event of facing lawful or unlawful, normal or abnormal activity of the Administration. Quoting Dr. Ernesto Jinesta Lobo, from his Work Tratado de Derecho Administrativo II, Responsabilidad Administrativa, p. 39, it is stated that: "In the system of no-fault liability or special sacrifice, liability for lawful conduct (conducta lícita) or normal functioning, the determining criterion for the existence of liability of public administrations is the breach of the principle of equality in the bearing of public burdens and the consequent special damage (small proportion of affected persons) and abnormal damage (intense exceptionality of the injury) or the risk theory for the hypothesis of accidental damages caused by a public administration in the fulfillment of the function assigned by the legal system. In the case of the system of liability for lack of service (falta de servicio) - unlawful conduct or abnormal functioning - the imputation criterion is constituted precisely by that indeterminate legal concept of 'lack of service' and the unnamed or atypical constitutional right of the administered to be provided with efficient and effective public services." In liability for unlawful or abnormal conduct, understood as that which opposes, infringes, or violates the legal system globally understood as written and unwritten norms, the burden of proof corresponds to the victim, who bears the duty to demonstrate, through the forms and evidentiary means permitted by the legal system, the lack of service, its abnormal functioning, or the unlawfulness of the administrative action. In liability for lawful conduct (conducta lícita), it has been established that even in the case of conduct carried out in accordance with the legal system, such conduct is susceptible to attributing liability to the Administration under criteria such as those related above. In cases of objective liability, the Administration's defense would lie in demonstrating that one of the causes that break the causal link indicated in numeral 190, paragraph 1 of the General Law of Public Administration has mediated, whether, as indicated above, force majeure (fuerza mayor), the act of a third party, or the act of the victim themselves. Our First Chamber (Sala Primera) of the Supreme Court of Justice in resolution No. 000584-F-2005, at 10:40 a.m. on August 11, 2005, indicated, always in relation to objective liability, the following: "...there shall be liability of the Administration whenever its normal or abnormal functioning causes a damage that the victim has no duty to bear, whether pecuniary or non-pecuniary, independently of their subjective legal situation and the ownership or condition of power they hold, complying, of course, with the essential prerequisite of the causal link. (...) Both the essential prerequisites and the burden of proof acquire, for example, a new nuance, which frees the affected person not only from substantive but also procedural ties, and places the Administration in the obliged discharge against the charges and facts imputed to it. In any case, the objective nature of the extracontractual civil liability of the Administration was clearly defined in the judgment of this Chamber No. 132 at 3:00 p.m. on August 14, 1991, for an event subsequent to the entry into force of the General Law of Public Administration, in which it stated: 'VI. Our General Law of Public Administration No. 6227 (...), as indicated in the judgment of this Chamber No. 81 of 1984, when resolving the controversy over its validity, in the Seventh Title of the First Book, adopted the most modern principles based on the most authoritative doctrine and jurisprudence on the extracontractual liability of the Administration, thus establishing the direct liability of the State without needing to previously prove that the damage was caused by the fault of the official or the Administration, requiring for the indemnity to proceed that the damage suffered be effective, assessable, and individualizable in relation to a person or group -Article 196-. (...) It also establishes, in an exhaustive manner, as exempting causes of that liability, force majeure (fuerza mayor), the fault of the victim (culpa de la víctima), and the act of a third party, it being the Administration's responsibility to prove their existence, (...)'" (The emphasis is not from the original). Specifically, regarding the potential liability of an entity like the Caja Costarricense del Seguro Social associated with the provision of health services under its charge, the First Chamber (Sala Primera) of the Court, in its Voto No. 7 at 2:20 p.m. on January 13, 1995, has also indicated as follows: "(...) It is this objective liability theory that requires that with the risk created, damage susceptible to indemnification is caused to the administered, (...). V)- In order to re-establish the liability of the Caja Costarricense de Seguro Social, the causal link between the damage caused to the plaintiff and the action of said entity must be recognized, that is, between the challenged act and the harmful event. (...) The causal relationship between the act (activity consisting of providing medical services) and the effect (...) is clear, unavoidable, and strictly referable to the sued institution. There is no need to remark on whether or not the patient was hypersensitive to the indicated medication, but only - as the expert affirmed (...) - that a risk was created that, as an exception to the common resistance of organisms, caused damage to the patient, and the patient has no reason to bear it without - at least - being compensated for it. In summary, the Caja Costarricense de Seguro Social created the risk, through its hospitals, causing damage to the patient, the plaintiff today, and consequently, based on the aforementioned risk theory, it must be held liable for its action." (The emphasis is not from the original). Consequently, and consistent with all the foregoing, the determination of the existence of the claimed damage would be sterile if, having been identified by the plaintiff, the alleged administrative conduct is not proven - in this case, the performance of medical procedures that do not lead to an adequate and timely diagnosis of the ailment the patient suffers - since, from the outset, it would not be possible to at least determine that, linked to the medical service provided to the plaintiff, a causal link (nexo causal) mediated that allows concluding that it was that procedure and not another circumstance that objectively and effectively constituted the genesis or origin of the alleged damage.- 2.- On the right to health and access to medical services. The right to health constitutes a fundamental right enshrined in the Political Constitution, if its numerals 21 and 50 are related (right to life as well as to a healthy and ecologically balanced environment). As a result, and to a large extent, its effective guarantee comes from a prestational exercise, this being because health services provided by hospital centers, among others, are those directly aimed at addressing health afflictions of the general population. Consequently, the State or its institutions - among which is the Caja Costarricense del Seguro Social and, to a different degree, the Instituto Nacional de Seguros in what corresponds to it according to the law - are mandated to adopt all necessary and positive measures or actions to guarantee that right in an adequate and reasonable manner. It is not superfluous to indicate that both institutions, among others - public and private - form part of what has been called the National Health System in accordance with the respective regulation, Articles 1 to 4, 9, 18, and 82, which was published in the Official Gazette “La Gaceta” number 230 of December 5, 1989, Executive Decree (Decreto Ejecutivo) number 19276-S of 11/09/1989. On the other hand, there are the deontological rules that govern the practice of the arts associated with health and medical science, as well as those directed at the regulation of hospital centers themselves - both public and private. The Constitutional Chamber (Sala Constitucional) has been responsible for the dimensioning of this right and thus, in its judgment number 2010-07602 at 2:49 p.m. on April 27, 2010, indicated in this regard that: "The World Health Organization (WHO) in its Constitution - adopted in New York in 1946 - defined health as the state of complete physical, mental, spiritual, emotional, and social well-being, and not merely the absence of affections or diseases. Regarding the right to health, in a broad sense, what was ordered by this Court in Voto No. 1915-92 at 2:12 p.m. on July 22, 1992, is illustrative, which, as relevant, states the following: '(...) the right to health has as its fundamental purpose to make the right to life effective, because this does not protect only the biological existence of the person, but also the other aspects derived from it. It is rightly said that the human being is the only being in nature with teleological conduct, because they live according to their ideas, ends, and spiritual aspirations; in this condition of a cultural being lies the explanation for the necessary protection that, in a civilized world, must be granted to their right to life in all its extension, consequently to a healthy life. If within the extensions that this right has is, as explained, the right to health or health care, this includes the State's duty to guarantee the prevention and treatment of diseases (...)' . Similarly, categorical is what was ordered by this Chamber in Judgment No. 11222-03 at 5:48 p.m. on September 30, 2003, stating the following: '(...) VI.- FUNDAMENTAL RIGHT TO HEALTH. The right to life recognized in numeral 21 of the Constitution is the cornerstone upon which rest the other fundamental rights of the inhabitants of the republic. In the same way, the right to health finds a basis in that article of the political charter, since life is inconceivable if the human person is not guaranteed minimum conditions for an adequate and harmonious psychic, physical, and environmental equilibrium (...)' . In this way, it must be underscored that the aforementioned fundamental right is guaranteed through actions directed at preserving human life in minimum conditions that foster an integral, adequate, and harmonious psychic, physical, and environmental equilibrium, all of which, of course, is directly applicable to the operation of hospital centers, as well as the practice of medical science, among other activities and sciences, as well as diverse professions that, in their exercise, affect this topic. Furthermore, the right to health is recognized at the level of international law, Article 25 of the Universal Declaration of Human Rights; 7 and 1 of the American Declaration, 3, 6, 23, and 24 of the Convention on the Rights of the Child. Consequently, and without losing sight that the legal operator must observe the principle of conventionality control, both the right of the Constitution and any instrument of international law that protects a right of this kind with greater force than it, will inform the interpretation and application of the infra-constitutional normative order in the resolution of problems in specific cases. Being of interest to us the topic linked to the provision of medical services, see also what was indicated by the Constitutional Chamber (Sala Constitucional) in its judgment number 2011-003683 at 3:47 p.m. on March 22, 2011, in which the following was stated: 'It suffices only to consult the International Covenant on Economic, Social and Cultural Rights, in its numeral 12, to realize what we have been affirming. In effect, in said international human rights instrument, the right of every person to enjoy the highest possible level of physical and mental health is clearly established, so the State and its institutions have the duty to ensure the full effectiveness of that right through a series of positive actions and the exercise of powers of regulation, oversight, and sanitary police. The foregoing means, neither more nor less, the prevention and effective treatment of diseases, as well as the creation of conditions that ensure for all medical assistance and quality medical services in case of illness. Having said the foregoing, the right to health includes the availability of health services and programs in sufficient quantity for the users of these services and recipients of these programs. On the other hand, the right to health also entails accessibility to these services and programs, whose four dimensions are non-discrimination in access to health services, physical accessibility - particularly by the most vulnerable -, economic accessibility - which entails equity and the affordable nature of health goods and services -, and accessibility to information. No less important is that health services and programs be acceptable, that is, respectful of medical ethics, culturally appropriate, directed at improving patients' health, confidential, etc. Lastly, and no less relevant for that, the right to health implies quality services and programs, which means that such services must be scientifically and medically appropriate."' Thus, taking the foregoing into account, we shall proceed to the analysis of the appropriateness or not of what is requested in the claim that is being heard under the terms of this present instrument.- 3.- On mandatory insurance for automotive vehicles. We deem it opportune, as it is synthetic yet integral at the same time, to cite what was stated in this regard by Section VIII (Sección VIII) of this Court in its judgment 110 - 2013 at 3:00 p.m. on November 28, 2013, an opportunity in which the following was noted on this topic: "IV.- (...) The so-called Mandatory Automobile Insurance (Seguro Obligatorio de Automóviles) corresponds to an instrument of protection and economic support (concreted contractually between the owner of a vehicle and a public or private insurer) for the possible affected parties in a traffic accident, which is imposed by the legal system on vehicle owners as an authorizing requirement for their movement within the national territory. Through it, drivers, passengers, and third parties - pedestrians or travelers - are covered in relation to the risk generated by the activity of driving a motor vehicle, which can eventually cause the death of citizens, or their total or partial disability, as well as medical, hospital, and rehabilitation expenses, per diems, food, or other assumptions - according to the parameters of the insurance -, covered through subsidies, in the event of a traffic accident. Certainly, it implicitly carries a public interest that, it must be clarified, does not imply a transmutation of said mechanism into a social security insurance, since the duty of its acquisition is linked and directed to the ownership of a vehicle and, consequently, whoever takes it out will establish a private contractual link with the insurance entity that provides the service. In that line, it must be highlighted that the limit of the quantum of the subsidies that may eventually be granted is subject, on one hand, to the type and degree of the injuries caused and, on the other hand, to the sum agreed upon between the private individual-insured and the insurance company, which is generally defined in an adhesion clause of the contract, which varies every certain period. Simultaneously, that insurance carries an element of protection of the patrimony of the vehicle owner (or its driver) responsible for the injury, who may unexpectedly come to face an economic strain due to the unforeseen provocation of an injury, so the SOA (Seguro Obligatorio de Automóviles) also functions as a means of compensation or balance of the patrimony of the party causing the damage, despite the fact that, eventually, that liability may exceed the agreed coverage, in which case, once the insurance amount is satisfied, the insurance entity disassociates itself from the matter, leaving the generator of the detriment directly obligated by constitutional imperative (numeral 41 of the Magna Carta), which was already indirectly addressed regarding mandatory insurances by the First Chamber (Sala Primera) of the Supreme Court of Justice through Voto No. 30-F-2005 at 10:45 a.m. on January 27, 2005. From a normative perspective, the SOA originates in the Ley de Tránsito, namely, No. 5322 of August 27, 1973, repealed by Law No. 5930 of September 13, 1976, which in turn was substituted by the Ley de Tránsito por las Vías Públicas Terrestres, No. 7331 of April 13, 1993, and its subsequent reforms. For the date on which the accident giving rise to this process occurred, the insurance amount was determined at three million colones, and Law No. 8696 of December 17, 2008, was applicable, as well as the Reglamento sobre el Seguro Obligatorio para Vehículos Automotores No. 25.370-MOPT-J-MP of July 4, 1996. In general terms, reference is made to the legal bases of importance for this type of insurance. Thus, ordinal 39 of the Law establishes the mandatory nature of said instrument, while providing the basis for the issuance of regulatory regulation. Numeral 49 expressly states: "The mandatory motor vehicle insurance covers the injury and death of persons, victims of a traffic accident, whether or not there is subjective liability of the driver. Likewise, it covers accidents produced with civil liability, arising from the possession, use, or maintenance of the vehicle. In this latter case, this liability must be determined through the established procedures and before the competent courts." For their part, ordinals 52 and 53 define the limits and the applicable economic benefits and, 51 indicates that the maximum coverage limit of the mandatory vehicle insurance shall be defined by the regulation to the Law, which is determined by Article 14 ...". (The emphasis is not from the original). Attention must be drawn to the fact that the Instituto Nacional de Seguros, in what it administers this insurance and at the same time directly provides health services through its hospital center, exercises functions that are divided in terms of their regulation, the first being of a commercial nature in accordance with an ordinary and principal economic activity - today liberalized within the framework of the insurance market - and on the other hand, a prestational one in terms of the provision of hospital services, which, whether associated or not with the coverage of an insurance policy, corresponds to an activity governed by special regulations, thus informed by the rules of the arts associated with medical science and, in this latter measure, by the deontological rules that govern medical action through the professionals in that area through whom a hospital acts.- 4.- On the nature of the services provided by the Instituto Nacional de Seguros. Although this topic might seem settled, due to its relevance for the issuance of the present ruling, it must be revisited. A special normative body in the field first implemented can be located starting from October second, nineteen hundred twenty-two, with the Ley de Seguros number 11, published in the corresponding Colección de Leyes y Decretos of that year, second semester, first volume, page 314, at a time when the activity linked to the possibility of commercially accepting, in exchange for the satisfaction of a premium, the transfer of risks to which third persons, being insurable, are exposed, was liberalized to free competition, so that in the event of the occurrence of any circumstance provided for that justifies it, an indemnity is dispensable that covers the economic burden such an event may generate, due to the harmful effects on the patrimony of the insured and/or their personal integrity. On October thirtieth, nineteen hundred twenty-four, Law number 12 of that date was enacted, today, the Law of the Instituto Nacional de Seguros, through which the previous Ley de Seguros was entirely repealed. An entity was created through it with the denomination Banco Nacional de Seguros, which would later mutate into an institute. The creation of this organization occurred according to numerals 4 and 5 of said law, foreseeing from then on the future monopolization of the market, being designed meanwhile so that the Banco Nacional de Seguros would serve to contract and carry out the State's insurances. Later, in Article 5 of this normative body, the Instituto Nacional de Seguros was created starting from the reform operated by Law number 4183 of September fourth, nineteen hundred sixty-eight, which, related to the supervening reform operated by Law number 6082 of August thirtieth, nineteen hundred seventy-seven, and Law 6082 of the same year, end up establishing the state monopoly, which resulted in this activity being exclusively under the administration of said institute, operating as an autonomous entity.- Currently, the Law of the National Insurance Institute is in force according to the text of its constitutive law, as amended by Article 52 of the Insurance Market Regulatory Law (Ley Reguladora del Mercado de Seguros), No. 8653 of July twenty-second, two thousand eight, published in the Official Gazette "La Gaceta," number 152, supplement 3, of August seventh of the same year. This reform came as a consequence of the obligations acquired by the State with its counterparts in the pertinent areas, on the occasion of the adoption of the Free Trade Agreement between the United States, Central America, and the Dominican Republic, approved by Law No. 8622 of November twenty-first, two thousand seven, published in the Official Gazette "La Gaceta," number 246, of December twenty-first of that same year, supplement 40. The resulting commitments of interest are located within the annex of the treaty corresponding to financial services and matters of insurance. (See Article 7 of the Constitution). Thus, Article 1 of the Law of the National Insurance Institute, amended by the Insurance Market Regulatory Law (Ley Reguladora del Mercado de Seguros), provided in the pertinent part as follows: <i>"The National Insurance Institute, hereinafter INS, is the autonomous insurance institution of the State, with its own legal personality and assets (personalidad jurídica y patrimonio propios), authorized to develop the insurance and reinsurance activity. In said activities, the regulation, supervision, and sanctioning regime provided for all insurance entities shall be applicable. / (...). / In the development of the insurance activity in the country, which includes the administration of commercial insurance, the administration of the Workers' Compensation Insurance (Seguro de Riesgos del Trabajo), and the Mandatory Automobile Insurance (Seguro Obligatorio de Vehículos Automotores), the INS shall have the full guarantee of the State. / The INS is empowered to constitute or acquire capital participations in corporations (sociedades anónimas), commercial companies, branches, agencies, or any other commercial entity of a similar nature, none of which shall have the guarantee indicated in the preceding paragraph, for the following purposes: a) To exercise the activities that have been entrusted to it by law within the country. Such activities include those of a financial nature, the granting of loans, </i><b>those of the provision of health services </b><i>and those specific to the Fire Department (Cuerpo de Bomberos), </i><b>the supply of medical benefits (prestaciones médicas) </b><i>and the sale of goods acquired by the INS by reason of its activities. / Additionally, the INS may establish, by itself or through its companies, strategic alliances with public or private entities in the country or abroad, with the sole purpose of fulfilling its competence. / Both the INS and its corporations, with the approval of the respective boards of directors, may incur debt prudently in accordance with the corresponding financial studies. These operations shall not have the guarantee of the State. / Public banks are authorized to participate as shareholders of the corporations that the INS establishes as indicated in this article, provided that the INS remains the majority shareholder of said companies"</i>. The text, as indicated, corresponds to the historical moment in which, as a result of the scope of the aforementioned free trade agreement, the existing monopoly is broken and the insurance market is completely opened to free competition for products associated with insurance in all its manifestations. From the outset, the indicated Article 1 corresponds to a legislative line strongly oriented towards reinforcing the capacity of the Institute to act under the private law regime so that, its activity being of public interest, it is directed towards successful participation in the free market of products associated with the insurance activity, as part of the productive sector of the State. The core or epicentral activity of the Institute, according to its constitutive law, is the commercialization of insurance products. However, there have also been others, such as associated financial activities, and another one outside this specific main commercial activity within the framework of a liberalized market, which is residually preserved—it must be said—as a product of those moments when the activity was under a state monopoly through it, such as the activity carried out by the Fire Department, which, before the reform occasioned by the same Insurance Market Regulatory Law (Ley Reguladora del Mercado de Seguros), was established as a body with minimal deconcentration (desconcentración mínima). Today, it is a body with instrumental legal personality (personería jurídica instrumental) and maximum deconcentration (desconcentración máxima), attached to the Institute according to the Law of the Meritorious Fire Department (Benemérito Cuerpo de Bomberos), No. 8338 of March 19, 2002, Articles 1 and 2. On the other hand, there are activities linked to medical benefits (prestaciones médicas), which originate in a direct link with the insurance activity, such that they are medical services through its own hospital centers or third parties with whom it associates for that purpose, which in both cases correspond to a private-sector service subject to the existence of an insurance contract, marketable by any authorized insurer, different from those that must be understood to be included within the social security services administered by the Costa Rican Social Security Fund (Caja Costarricense del Seguro Social, CCSS), the latter being those for which their nature as a service openly available to the public on a universal basis can be affirmed. These medical services provided by the Institute, as could be provided by any authorized third party, it is insisted, clearly correspond to the effects and scope of services associated as a benefit to some of its products, such as so-called personal insurance. On this matter, the constituent foresaw something from the content given to Article 73 of the Magna Carta (Carta Magna), by determining a special regime to be developed by the ordinary legislator and distinct from that corresponding to social insurance for the case of mandatory workers' compensation insurance (seguros obligatorios para riesgos del trabajo), established with the purpose of protecting workers, charged to their employer, serving as a mechanism for access to health services. This is an insurance that operates as an exclusive obligation of employers towards the workers with whom they are linked, that is, charged exclusively to their assets and as determined by the corresponding regulations. Due to this, the employer must mandatorily acquire the corresponding insurance product within the market in order to comply with this provision, just as it is mandatory for owners of automobiles to pay, in order to access the right to circulation, the corresponding mandatory insurance, which would cover, at its core, death and/or the care of injuries caused by a traffic accident. Currently, the Insurance Market Regulatory Law (Ley Reguladora del Mercado de Seguros), which, as an effect of the Free Trade Agreement noted above, led to the opening of the market to such a degree that both the mandatory automobile insurance and workers' compensation insurance were included under the terms provided in Transitory Provision III of that law, related to its Article 2, last paragraph, with only the mandatory social security systems administered by the Costa Rican Social Security Fund (Caja Costarricense del Seguro Social, CCSS) and the special pension regimes created by law and the mandatory mutual policy administered by the National Teachers' Life Insurance Society (Sociedad de Seguros de Vida del Magisterio Nacional) being excepted from the application of this regulation and, therefore, outside free trade, indicates that the health services provided by the Institute are not social-type services with the openness of those provided by the Costa Rican Social Security Fund (Caja Costarricense del Seguro Social, CCSS). This liberalization could be seen as acceptable under Constitutional law, since the Constitutional Chamber (Sala Constitucional) in its ruling No. 2001-12952, at sixteen hours and twenty-four minutes on December eighteen, two thousand one, affirmed as follows: <i>"</i><b>II.- </b><i>The second and third points of the consultation are intimately linked, as they both start from the premise that the National Insurance Institute has been constitutionally assigned competence in the matter of workers' compensation, which is inaccurate. Constitutional Article 73 clearly states that 'Insurance against professional risks shall be at the exclusive expense of the employers and shall be governed by special provisions,' from which it is concluded that it is the law that is responsible for developing them. Constitutional Article 188 merely indicates that the State insurers are autonomous institutions, and from this provision, </i><b>it cannot be validly concluded that the Constitution has granted the INS exclusive competence in the matter of workers' compensation</b><i>. Workers' compensation insurance, as a State monopoly, originates in Law No. 12 of the month of October 1924; by Law No. 33 of December 23, 1936, the National Insurance Institute came into legal existence, to which the competence was maintained to </i><b>commercialize, among other types of insurance, the workers' compensation insurance in question</b><i>. </i><b>Subsequently, Constitutional Article 73 established workers' compensation insurance <i>'</i></b> <b>at the expense of the employers<i>'</i></b> <b>leaving the regulation to the ordinary law, which has not undergone any modification, and therefore the National Insurance Institute has maintained that competence over the years</b><i>. The reading of the Acts of the National Constituent Assembly (Asamblea Nacional Constituyente) clearly shows us that Article 73 was drafted in a broad manner to allow, in the future, that matters related to disability, old age, death, and workers' compensation insurance would be under a single direction; consequently, the establishment of logical coadjuvancy between State institutions cannot be considered contrary to the constitutional order, for which it is not necessary to comply with the hearing procedure that the consultants miss"</i>. (The highlighting is not from the original). Well, the legislator took account of this type of autonomous organization, like the defendant Institute, when enacting the General Law of Public Administration (Ley General de la Administración Pública), No. 6227, in nineteen seventy-eight. According to its Articles 01 to 3, the Public Administration, through its various organic manifestations, has the capacity under public and private law to act, and subsequently, public law being the one that governs State activity, although it also applies to other public entities distinct from it, such as decentralized ones, it does so as long as there is no law to the contrary. For this reason, it is possible for private law to regulate a specific activity of those entities when there is a law that so indicates, something that can well occur because, due to their overall regime and the requirements of their line of business, they must be considered as common industrial or commercial enterprises. The foregoing is reinforced if one observes the content of Articles 111 and 112 of the same legal body in what it regulates the service relationships between the Administration and its agents, when these do not participate in what can be understood as public management, or who participate in a legal relationship with public enterprises or State economic services in charge of operations subject to common law. By finalist principle of interpretation of norms and without prejudice to ideological positions that in the past and present shade what will be said in a diverse way, from its existence once the General Law of Public Administration (Ley General de la Administración Pública) was enacted, and later, with the foregoing being reinforced and qualified from the entry into force of the Securities Market Regulatory Law (Ley Reguladora del Mercado de Valores), informed by the scope of the Free Trade Agreement between the United States, Central America, and the Dominican Republic, approved by Law No. 8622, it is clear that the legal nature of the National Insurance Institute is that of a public state enterprise, created under a form of Public Law, notwithstanding this, created for the provision of commercial services regulated by common law. The organization is situated within the framework of what is understood as within the productive sector of the institutional public decentralized organization. Article 2 of the Law of the National Insurance Institute must be observed in what it states as follows: <i>"Application of Private Law. The acts generated from the development of its commercial insurance activity, acting as a common commercial enterprise, shall be regulated by private law, so that in the exercise of the insurance activity, the Institute shall be subject to the jurisdiction of the ordinary courts"</i>. From the foregoing, as a derivation, given the activity that this entity legally carries out, none of its manifestations is or constitutes a public service, as they do not share the characteristics of one, except for the one associated with fire extinguishing, residing in a legal body that is attached to it, such as the Fire Department, without this particular activity constituting the neuralgic axis of the entity. It should be noted that even including the commercialization of mandatory automobile insurance or workers' compensation insurance within the Institute's activity, due to whatever social interest these may have, they are personal insurance products in the insurance market that today can be offered by any authorized participant, therefore they do not differ in any way from the rest of the products associated with this insurance market, becoming goods and services of a commercial nature in all their aspects. This affirmation is reinforced within the framework of a market liberalization to free competition in insurance matters, within which the legislator has also committed to reinforcing this institution's capacity in the deployment of its ability to act governed by private law, in order to ensure its successful participation within a framework of equality in the market against other participants, a capacity that has been powerfully projected not only to administer the management of its attributions and competencies but also to self-organize for these purposes. The fact that the assets administered by the Institute form part of the public treasury's holdings does not say anything that does not also apply to other public state enterprises that, like this one, exercise a commercial activity subject to private law, but at the same time, subject to certain controls that for each institution can vary in degree and intensity. (Articles 8 and 9 of the Organic Law of the Office of the Comptroller General of the Republic (Ley Orgánica de la Contraloría General de la República)). Well, it being necessary to note, as indicated above, that whether or not associated with the application of a product within the framework of a commercial insurance activity, both the conduct deployed towards the plaintiff by the National Insurance Institute and by the Costa Rican Social Security Fund (Caja Costarricense del Seguro Social, CCSS) proved to be out of step with the legal order, meaning that in terms of benefits, they constituted, at different levels, abnormal conducts that make what is partially claimed admissible, as will be seen, for they serve as criteria for the imputation of patrimonial liability (responsabilidad patrimonial) because they also constituted the origin of a moral damage intensely experienced by the plaintiff, which must...- **5.- On the partial admissibility of the claim against the Costa Rican Social Security Fund (Caja Costarricense del Seguro Social). **This Tribunal considers it appropriate to begin this section related to what, according to the facts that have been considered proven, is relevant for the resolution of the point in question.

**5.1.- **In relation to this part, it is held that on March 8, 2012, Mr. Gilberto Badilla Castro suffered a traffic accident, as a product of which he presented injuries that warranted his transfer to a hospital, in this case, to the San Juan de Dios Hospital. (Uncontested fact, in relation to page 108 of the clinical file of the San Juan de Dios Hospital, in its volume I, and page 120 of the INS clinical file, in its volume I, as well as pages 65 and 36, of the INS evidence file, as well as page 10 of the file for the precautionary measure, pages 85, 86, and 78 of the main file). In that nosocomio, the plaintiff was attended to, was given primary care and was stabilized, and was later referred to the INS, exclusively because it came to the institution's knowledge that he was covered by a policy of the mandatory automobile insurance. (Uncontested fact, in relation to the testimony given in a supplementary hearing by Dr. Javier Francisco Soto Fallas). A separate point as to whether this was appropriate or not, it was an uncontested fact, which is also supported by the evidence found on page 75 of the file identified as INS evidence. Well, indeed the plaintiff was protected by a policy of this type, but it would have corresponded to a liberality on his part to remain in that medical center in order to receive medical attention—San Juan de Dios Hospital—or to be transferred, in his case, to the INS, given that the application of the mentioned policy not only corresponds to a right that pertains exclusively to him and is waivable, but also that, at the time he suffered the traffic accident, he was directly insured by his employer as a salaried worker before the CCSS. (Uncontested fact, in relation to page 11 of the file for the precautionary measure wherein a copy of the valid employer order for the month of the accident's occurrence is recorded, as well as page 79 of the main file wherein a copy of the card accrediting him as a directly insured person is recorded). Without prejudice to the fact that it is clear that whether insured by the INS or not, the plaintiff was insured at the time by the CCSS, the provision of Article 23 of the Regulation on Mandatory Automobile Insurance (Reglamento sobre el Seguro Obligatorio para Vehículos Automotores) is consistent, which reads as follows in the pertinent part: <i>"The health care benefits (prestaciones sanitarias) established by this insurance shall begin to be provided by the doctors of the National Insurance Institute or those designated by it, or, indeed, contracted by the victim in their condition as an injured party, but in this last case, the cost of the health care benefits that said Institute will recognize shall be subject, in order, to the rates in force for similar services provided by the Institute, or, failing that, those of the Costa Rican Social Security Fund (Caja Costarricense del Seguro Social), and lastly, those defined in agreements signed between the Institute and private individuals, without prejudice that the professional or the victims, if applicable, could collect the difference from the party responsible for the accident"</i>. That is, the person insured by the INS in any case retains the right to choose by whom to be treated, which does not exclude the application of their policy, such that it could not be affirmed under the non-legal principle that whoever can do more can do less, that they could not choose to be treated by the CCSS, either under the mandatory automobile insurance or simply by the fact of being insured before said institution providing health services. Along these lines of thought, see that Dr. Javier Francisco Soto Fallas, a specialist at the San Juan de Dios Hospital, reported in court that when a patient with injuries caused by a traffic accident is admitted, what is usually done with them is to ask if they are covered by a mandatory automobile insurance policy or not, so that if they indicate yes, they are referred to the INS, apparently by automatism. It must be added that no evidence exists in the administrative files that the plaintiff was informed of his rights in this regard, as well as that his referral to the INS corresponded to his will, although this aspect is not central to the resolution of the present matter insofar as there is also no record or statement from him that he acted against his will. Well, having been referred to the INS by the medical authorities of the San Juan de Dios Hospital, the plaintiff entered that state enterprise (INS Salud) on March 9, 2012, where he was hospitalized and provided with care. On March 12, 2012, he was assessed in the orthopedics service by the doctor identified with the name of Max Rojas Badilla (a witness whom, in the present case, having been admitted as evidence, the representation of the INS waived in the trial hearing) who diagnosed the presence of a transcervical fracture in the neck of the left femur of the left hip, requiring surgery, for which, as a first order of business, an element associated with a prior existing osteosynthesis in the femur had to be removed, with both operations needing to be performed simultaneously. (This can be seen on pages 85 and 86 of the main file). Already at the INS, on March 17, 2012, and as part of the service provided to the plaintiff, he was transferred to Hospital La Católica, where that surgical intervention was performed on him by the same doctor, Max Rojas Carranza. This, besides not being a contested fact, is recorded on pages 39 and 40 of the INS evidence file. Two days later, on March 19, 2012, the plaintiff had been transferred again to the INS, where it was reported by its medical staff that due to his obesity a better reduction was not possible, with a risk of necrosis or pseudoarthrosis of the hip. (This is extracted from the review of pages 12 of the main file, in relation to pages 84 and 109 of the file for the precautionary measure and the testimony in the supplementary hearing by Dr. Javier Francisco Soto Fallas, who explained the surgical procedure performed at trial). Then, by March 21, 2012, the plaintiff had been discharged by the medical authorities of the INS to his home. (Uncontested fact given the statements of the INS representation in its brief contesting the claim). By March 27, 2012, the coverage amount of the mandatory automobile insurance policy under which Mr. Gilberto Badilla Castro was being treated at the INS had been exhausted, as evidenced on page 15 of the file for the precautionary measure, and this would later explain the conduct adopted by that state enterprise. Prior to this, on April 9, 2012, the plaintiff had moved to the INS, where, because Dr. Max Rojas Carranza was not present, he was attended to by Dr. Javier Castro Figuls, who noted that his hip had three nails with some "varo," that is, "curvature," and diagnosed that <b>in the surgery performed, there was damage to the hip</b>, proceeded to remove the "avión" which is the device used to prevent rotation of the hip that had been placed after surgery, and scheduled an appointment for the following April 23, and finally, he was sent home again. (This is a fact that is considered proven as a result of not having been contested given the statements of the INS representation in the brief contesting the claim, since it was outlined in the claim brief and was not rejected in that respect). An appointment, which must be understood as a follow-up, had been scheduled for the plaintiff, however, prior to this, on April 12, 2012, he presented himself at the INS again, where Dr. Max Rojas Carranza—who had previously treated him—merely reviewed the insurance policy with which he had been given care, proceeded to issue a discharge summary (epicrisis), and proceeded to transfer the plaintiff to the Costa Rican Social Security Fund (Caja Costarricense del Seguro Social) because the coverage amount of that policy had been exhausted—which we said occurred on March 27, 2012—with an indication in the referral <b>that it was to the orthopedics service and <u>as urgent</u></b>. (This fact constituted one on which there was no controversy as it was not rejected by the representation of the INS in its brief contesting the claim, which is also supported given page 189 of the INS clinical file, where the corresponding medical notes report is recorded). That was the state of things on April 17, 2012, the same day on which, having been told the plaintiff that he would no longer be treated at the INS due to what was said, he was admitted to the San Juan de Dios Hospital according to the medical referral indicated, where he was assessed by Dr. Daniel Martínez Castrido, who indicated <b>that there had been a failure in one of the procedures performed</b>, specifically the osteosynthesis, presenting migrated screws, displaced femoral head and neck, and that this corresponded to a complication of the surgery performed by the INS doctor, so that, considering that this circumstance excluded the Costa Rican Social Security Fund's (Caja Costarricense del Seguro Social) responsibility for care, <b>the patient should be given a counter-referral to the INS</b>.

Thus, he was discharged from Hospital San Juan de Dios that same day, April 17, 2012, with the referenced failure in the procedure carried out at the INS consisting of the bone and/or its fragments, despite the osteosynthesis (osteosíntesis) performed, not being properly aligned for the consolidation of the fracture. (Uncontested fact, given the statements of the CCSS representative in their answer to the complaint, in conjunction with folio 20 of the precautionary measure file and the trial testimony of Dr. Javier Francisco Soto Fallas, who properly explained at trial the matter, in relation to the patient's condition at that time and what had been recorded regarding the failure in the related procedure). Thus, on the same day, April 17, 2012, a counter-referral was issued from Hospital San Juan de Dios for him to be treated at the INS. On this matter, Dr. Javier Francisco Soto Fallas explained with certainty and propriety at trial that for things to have been handled as indicated, relevant medical reasons would have been involved. While it is irrelevant for the resolution of this matter whether or not there was medical malpractice on the part of the INS medical staff, particularly the physician who surgically operated on the plaintiff, Mr. Max Rojas Carranza, witness Javier Soto Fallas reported that despite the INS having performed a procedure known as osteosynthesis (osteosíntesis) on the plaintiff, through which the aim is to reposition the fractured bone in a position such that its consolidation is achieved by placing, among other elements, screws or possibly plates, the truth of the matter is that upon receiving the patient it was observed that the bone was displaced and, thus, the screws intended to prevent this were poorly implanted, so on two levels, what was appropriate from a medical standpoint first, was that since these were eventual complications presented in the procedure, it should be the same doctor who performed the intervention who would observe the plaintiff again, determining what complications arose in the specific case, as well as the necessary corrections that should be applied to remedy the patient's health problem. Furthermore, he explained in response to questions posed by the Court that there was also a deontological, if not ethical, issue that imposed upon the treating physician at the INS the duty to return to the evaluation and correction of the patient's situation, if his actions could not remedy the problems Mr. Badilla was suffering -the fracture- this being associated with the duties that govern the exercise of the medical profession as this Court understands it. This being the situation, it was Mrs. Mayra Torres Tapia who went to the INS to implore insistently —as she clearly ensured in her deposition as a witness at trial, without any reason to doubt the truthfulness of her statement— that care be given to Mr. Gilberto Badilla Castro, given that he would not receive it at Hospital San Juan de Dios per the aforementioned counter-referral, a request that was rejected solely on the grounds that the coverage of the policy had been exhausted, remitting him again to the CCSS, with a referral and epicrisis, but without evaluating the patient again. (This corresponds to a fact not contested in part, given the statements of the INS representative in their answer to the complaint, who does not reject this circumstance, in relation to the statement of Mrs. Mayra Torres Tapia in the supplementary trial hearing). Given the above, on April 20, 2012, Mr. Gilberto Badilla Castro appeared at Hospital San Juan de Dios, where without being evaluated again and for the same reasons for which he had been referred to the INS, the medical staff of the CCSS insisted that he should be treated at the INS; however, a follow-up appointment was scheduled for April 26, 2012 —leaving no doubt that the stance was still that the INS should be the one treating Mr. Badilla. (Uncontested fact, given the statements of the CCSS representative in their answer to the complaint). Dr. Javier Francisco Soto Fallas was clear that the mentioned appointment was meant to decide how to act depending on the treatment the plaintiff received at the INS, and whether or not he was treated, and how. Despite all this, on the day his follow-up appointment was scheduled, namely April 26, 2012, the plaintiff was received at Hospital San Juan de Dios, where that same day it was recorded —again— by a note from the treating physician Javier Francisco Soto Fallas, in which he recorded the following: *“Patient referred from INS due to policy exhaustion. However, today presents with a history of left femur fracture at the hip level with transcervical tracing, surgery was performed at the INS on 03/17/2012 with failure in the osteosynthesis (osteosíntesis), presents with migrated screws and displaced head and neck. At this moment, operating is not considered an emergency and from a medico-legal standpoint it is a complication of the surgery performed by the INS physician, who must assume it clinically with limitation to hip flexion due to its displacement”*, that is, after applying a surgical procedure to the patient through which external devices such as screws, plates, nails, etc., were placed to align and/or join the bone or its fragments in order to promote the consolidation of the fracture, through the formation of bone bridges and newly formed or new blood vessels that in both cases allow the transfer of the inputs the bone uses to consolidate, this had not been achieved. The plaintiff was transferred to his home, with performing an operation even in that state not being considered an emergency, and furthermore, and as a main consideration, that the condition he presented was associated with or was a product of the osteosynthesis (osteosíntesis) procedure applied to him by the INS without a positive result. (Folio 116 of the clinical file of Hospital San Juan de Dios, in its Volume I, in relation to folio 34 of the same file in its Volume II, the statements of the CCSS representative in their answer to the complaint, and the trial testimony from Dr. Javier Francisco Soto Fallas). The failure in the procedure had already been detected by the medical staff of the INS as stated before, since that same day, April 17, 2012, a time when a complication associated with the patient's obesity was mentioned. Meanwhile, neither at Hospital San Juan de Dios nor at the INS was the plaintiff being treated to correct his fracture in his hip. Finally, the plaintiff resorted to this Jurisdiction in a precautionary action ante causam, as a result of which on May 30, 2012, within this case, the order identified with number 266-2012 was issued, by virtue of which it was ordered exclusively to the CCSS *“...to provide full medical care to Mr. Gilberto Enrique Badilla Castro regarding any health condition he may be suffering from, whether due to the consequences of the traffic accident itself he suffered, or due to the surgical operations and/or treatments that may have been or not been performed on him by third parties without any distinction whatsoever”*. (See folios 88 to 96 of the precautionary measure file). Whether or not an appointment for the plaintiff had been scheduled previously by that medical center for a date before or after the adoption of the precautionary measure, the correct statement is that it was not for the purpose of performing any procedure that, as will be seen, was necessary to correct the fracture he presented in his hip, but rather and having heard the trial statements of Dr. Soto Fallas, it was to decide what to do depending on what the INS did on its own account, this, despite the fact that having been denied care at the INS, the plaintiff had also been rejected at Hospital San Juan de Dios on two occasions with knowledge of that circumstance, while the fracture he presented did not consolidate due to the result of the procedure performed at the INS, or where appropriate due to complications arising from the plaintiff's physical circumstances —which we insist, is irrelevant, insofar as the plaintiff was not being treated in any way to directly correct his ailment —. Thus, it was due to what was ordered in the precautionary measure that on May 31, the plaintiff was received again at Hospital San Juan de Dios (fact not contested in part, in conjunction with the statements of Mrs. Mayra Torres Tapia) at which point the standard preparatory examinations were performed, and it was determined necessary to alleviate his condition —the fracture— to perform a surgical intervention, which was successfully performed on June 25, 2012. Nothing allows us to affirm that this could not have been determined weeks before. In that operation, Mr. Badilla underwent a total hip replacement, not without first removing three cannulated screws placed by the INS in its time, as is clearly inferred, and prior to the intervention it had been verified that the plaintiff presented death or disappearance of bone material. (Folios 02 to 24 of the clinical file of Hospital San Juan de Dios, in its Volume I, in relation to the trial testimony of Dr. Javier Francisco Soto Fallas, folio 84 of the precautionary measure file, and folios 21 and 22 of the main file). Dr. Javier Francisco Soto Fallas explained at trial that the normal or usual procedure for a hip fracture is to hospitalize the patient and operate on them surgically, to take the necessary actions, either to adequately consolidate the fracture, or to replace the hip. On the other hand, he also explained that the procedure identified as osteosynthesis (osteosíntesis) that was performed on Mr. Gilberto Badilla Castro at Hospital La Católica at the request of the INS, was performed with a failure that, if it did not delay, prevented the consolidation of the hip fracture he presented. (The trial testimony of Dr. Javier Francisco Soto Fallas). It must be emphasized that whether the plaintiff was insured by the INS or not, at the time he suffered the traffic accident and was treated in both hospitals, he was insured by his employer as an employee with the Caja Costarricense de Seguro Social, he worked as a private security officer, and he was in a common-law union with the person identified as Mayra Torres Tapia, the latter being the one who took care of the plaintiff during his convalescence, in his home. (Uncontested fact, in relation to the statements of the plaintiff in his complaint, and at trial, by Mrs. Mayra Torres Tapia, and folio 11 of the precautionary measure file, 79 of the main file). It was also proven that from April 17 to May 31, 2012, neither at the CCSS nor at the INS did their staff consider themselves responsible for providing direct and principal treatment to the plaintiff aimed at correcting his condition —the fracture—. (Uncontested fact) **5.2.-** It is concluded from the foregoing that the CCSS, through the service provided to the plaintiff at Hospital San Juan de Dios by its officials, incurred in abnormal conduct in the area of providing medical services, which constitutes conduct misaligned with the legal system and grounds for the imputation of patrimonial liability, under an exclusive causal link in relation to the subjective moral damages claimed by the plaintiff, but partially, as was stated earlier, and from the moment it denied to one of its insureds the medical care that, it is ultimately known, was required, under the argument that this was the responsibility of the INS. It must be indicated that whether or not the reasons that, from the standpoint of the officials of Hospital San Juan de Dios, led them to refer the patient to the INS were true, the fact is that once his care was rejected by that Institute, they were obliged to treat him without any delay, or where appropriate, to investigate with the INS its reasons for proceeding and to immediately define what to do with the plaintiff. It has no relevance for the purposes of the CCSS, to analyze the scope of the mandatory vehicle insurance, when in any case the plaintiff was a direct insured as an employee under the regime administered by this sued Public Administration. Thus, the medical authorities of Hospital San Juan de Dios should have taken note that regardless of the patient presenting a problem associated with a failure in the procedure performed by the INS, and that in their opinion, whether for medical reasons, or for civil liability reasons, it was the INS's responsibility to correct the problem, the fact is that it was the plaintiff's prerogative to decide whether he wished to be treated by the CCSS or not. Even if his opinion on the matter was sought, note that by April 17, 2012, it was at least known —or at least should have been known by the medical staff of Hospital San Juan de Dios— that the plaintiff had been referred by the INS, due to his policy having been exhausted, which could have provided some foresight on the fate Mr. Badilla would meet upon presenting himself before that insurance company. In this way, prior to counter-referring the plaintiff to the INS to be treated under his policy and/or where appropriate, due to a medical duty imposed by medical reasons and/or deontological principles, the fact is that an eventual rejection of the patient was a completely expectable or at least possible outcome —as indeed it was—. Nothing supposes that it was not the CCSS's duty to treat the ailment the patient suffered efficiently and directly, without prejudice to what was done by the INS medical staff, the plaintiff being a direct insured under the regime administered by the CCSS, and at least, if it was deemed that his care should be provided by the INS, having received the plaintiff after his care was rejected by the INS —that circumstance being known— the least that could be expected was that, prior to counter-referring the patient, it be verified with the INS whether or not he would be treated beforehand, instead of leaving the patient to his fate, as was done illegitimately. The access to the health service by an insured person like the plaintiff cannot be conditioned or left to a third party without having certainty that he will be treated. In the plaintiff's case, in addition to the above, according to the trial statements of Dr. Javier Francisco Soto Fallas, the normal procedure for a hip fracture case is surgical intervention, to, on that occasion, correct the position of the bone —for which the implant of screws or plates can be used— with the purpose of placing the bone structure in a position that seeks the adequate consolidation of the fracture. Furthermore, his testimony was in agreement with that given by Mrs. Mayra Torres Tapia, that two days after this intervention is performed, it is expectable that the patient can even take steps. Contrary to this, in an improper manner, it was imposed upon the plaintiff, given the conflict between both institutions regarding the responsibility of performing this procedure, which was nonetheless necessary for the plaintiff according to the actions of the CCSS as of May 31, 2012, to wait, even indefinitely while the dispute continued, until it was not until the precautionary intervention by judicial order issued against the CCSS that the due care was provided to the plaintiff. From the foregoing, it is clear that the plaintiff indeed suffered abandonment in terms of the provision of health services that should have been timely provided, and this circumstance persisted at least from April 17 to May 31, 2012, as reproached by the plaintiff and according to the cause of action expressed in his complaint, as a consequence of which, it is established that there was administrative conduct by the CCSS medical staff adopted in misalignment with the legal system, which corresponds to abnormal conduct in the area of service provision, from which, as will be seen, damage emerged that must be compensated for the plaintiff as he is not obliged to bear it, nor is there any cause that breaks that causal link that must exist according to the doctrine that informs the provisions of Article 41 of the Constitution and 190 of the Ley General de la Administración Pública.- **5.3.-** Having systematically analyzed the evidence existing in this regard, it is derived mainly from the statements of Mrs. Mayra Torres Tapia in the supplementary trial hearing, in conjunction with the rules of 2012, was to find relief from the intense pain he suffered, as well as to free himself from his disabling condition that prevented him from moving by himself, aggravated by his obesity and caused by the existence of a fracture in his hip resulting from a traffic accident. During that period of time the two sued institutions, in principle called upon to solve his situation accordingly, denied him care, for diverse reasons. Setting aside the considerations to be made regarding the INS, it is clear that the plaintiff was not only aware of his right to be treated by the CCSS by virtue of being a direct insured as an employee, but also of the injustice represented by the denial of service. On the other hand, Mrs. Mayra Torres Tapia's statements were clear and credible, in what they were directed to describing the physical and emotional state of the plaintiff during that period of time, within which, for his care, given, among other things, his economic conditions, they were unable to provide conditions for his care, or at least for his waiting to be as comfortable as possible. In fact, she described how the plaintiff had to remain for hours and during days without anyone assisting him in his home from the early hours of the morning until night, as well as elaborating on the precarious economic situations they went through. She was also emphatic in informing this Court how she witnessed that the plaintiff experienced great pain, as well as feelings that this Chamber could not help but describe on its own, such as impotence, anguish, unease, frustration, anger, sadness, desperation, negative alterations in his character and ability to interact with the person who was providing him care insofar as she could —his common-law partner, Mrs. Mayra Torres Tapia— even desires not to live, all due to the fact that neither at the CCSS nor at the INS did their staff consider themselves responsible for giving him direct treatment aimed at correcting the state he was in, while he needs, given that, among other things, he was unable to fend for himself. The simplest rules of logic associated with experience, as well as the statements of Dr. Soto Fallas, in which he was in agreement that a situation like the plaintiff's produces pain, which, clearly, each person has a greater or lesser capacity to tolerate, account for the fact that if the plaintiff had to fend for himself during that period of time just as Mrs. Torres Tapia indicated, when she could not look after him while working from seven in the morning until eight o'clock at night, without a doubt, to attend to the simplest of his needs he must have experienced great pain —to which is added that the device previously placed to prevent the mobility of his hip had been removed—. The described feelings, associated with him being aware that his right to health was being injured, without a doubt, in any person would have caused a strong feeling of frustration and anxiety. With all this, this Court considers that the liability corresponding will not be joint and several, since the criterion for imputation is very different from that applicable to the INS's case as will be seen, in addition to us considering that the sum claimed is not in accordance with the intensity with which the plaintiff experienced the harmful effects described. The legal nature of this entity and the service it provides through the hospitals it administers, we consider, imposes a greater reproach of liability compared to what can be attributed to the INS, which provides private-type services. Thus, we consider reasonable and adequate to the merit of the circumstances the plaintiff went through, to award the sum of fifteen million colones as subjective moral damages, which must be paid by the CCSS in favor of Mr. Badilla Castro once this judgment becomes final, as is indeed ordered.- **6.- On the partial admissibility of the** **complaint against the Instituto Nacional de Seguros.** Regarding the Instituto Nacional de Seguros, this Chamber is of the opinion that having denied care to the plaintiff because his insurance policy was exhausted regarding the amount of its coverage, although in principle it conformed to what is dictated by the Ley de Tránsito por las Vías Públicas Terrestres, it cannot be considered conduct aligned with the law, if the legal system as a whole is applied to the specific case, but in the area of the provision of medical services through the operation of a hospital center. This Court is of the opinion that a separation must be made here between what constitutes a provision of services under the content and scope of an insurance contract and what corresponds to the obligations imposed by the legal system in a matter different from that one, which is the provision of services such as those provided to the plaintiff once he was accepted as a patient at the Hospital administered by the INS. On this particular topic, the existing regulation is directly applicable to the INS insofar as it treats a patient in its hospital center, which includes constitutional and international law that establish as a fundamental and human right, the right to and access to health services, which at all times must be comprehensive and must place, at the pinnacle of whatever the institutional interest may be, the well-being, also comprehensive, of the treated subject. We must start from the fact that it was established as a proven fact that the opinion of the CCSS doctors upon receiving the plaintiff after surgery was performed on him at the INS, was that he presented a failure derived from the procedure performed on him, which prevented the consolidation of the fracture in his hip, so that it was their opinion, even for medical reasons, that he should be treated by the same physician who performed such failed procedure. The core issue is to determine if the INS's action, in applying what it understands to be the scope of the mandatory vehicle insurance, has the power to exclude its responsibility. The answer is negative in the opinion of this chamber. We must insist that whether an insurance contract exists or not, once a patient is received by the INS and given medical treatment on its account, it is at the same time governed by the regulations that prevail in the area of the provision of medical services, the operation of hospitals, the duties and rights of the users of these services, and in what corresponds, both the Reglamento General Sistema Nacional Salud and the Código de Moral Médica that govern the professional practice of the officials who treated the plaintiff directly and/or, from their position as hospital medical authorities. We will begin by stating that after the surgery performed on the plaintiff, the referral made of him to the CCSS due to the exhaustion of his policy, is not in itself, a circumstance for which liability must be imputed to the company. A different matter occurs after care is denied to the plaintiff and the manner in which things were handled in that regard, after he is counter-referred by Hospital San Juan de Dios. Firstly, this not having been denied by the INS representative, through Mrs. Mayra Torres Tapia, the INS was implored for care for the plaintiff because at the CCSS the service was being denied and he was exclusively on the exhaustion of his policy, is not admissible, as the duty of its medical staff was to have inquired about the reasons why Hospital San Juan de Dios was referring him back. This was entirely omitted in the face of the efforts made on the plaintiff's behalf, being duly authorized for this, by Mrs. Mayra Torres Tapia. The plaintiff presented a failure in the medical procedure carried out by the INS in the opinion of the CCSS, so its staff had the responsibility to verify whether or not this was the case at least, in order to then decide —whether costs are generated or not— how to proceed with the patient who was already known, and was not being accepted by the CCSS. Contrary to this, it decided simply not to evaluate the plaintiff's case and to leave him to his fate, knowing that at Hospital San Juan de Dios he would not be treated. A minimum of diligence in the face of the plaintiff's situation would have been, prior to denying him care, to verify with the staff of Hospital San Juan de Dios whether or not they would receive him back.

The counter-referral to the INS was based—rightly or wrongly, and among other reasons—on medical grounds, including deontological ones, as stated by the physician at Hospital San Juan de Dios, Dr. Javier Francisco Soto Fallas, such that the refusal of care by the INS would have been expected to be based on reasons of the same nature, and not on contractual grounds depending on the scope of an insurance contract, since its activity merges the provision of health services with that of operating in the insurance market, without the latter activity excluding the regulations governing the operation of a hospital. Within the framework of the provision of hospital services, it is worth noting that Executive Decree No. 19276, of November 9, 1989, General Regulations of the National Health System (Reglamento General del Sistema Nacional de Salud), provides that the INS, together with the CCSS and the other public and private institutions indicated therein, form part of said system, and must act in an articulated manner, that is, systematically and in coordination. Its Article 9 states that: *“In order to guarantee comprehensive health care for the entire population, the right of all citizens to receive health services is recognized, at the facilities of the Ministry of Health (Ministerio de Salud), the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social) and the National Insurance Institute (Instituto Nacional de Seguros); consequently, the provision of comprehensive health services may not be denied to any particular person, without prejudice to subsequent verifications and corresponding charges when applicable”*. A member of the system according to Article 11 is the INS, which is conceived as a: *“... institution that helps to broadly and socially beneficially reduce the economic uncertainty that members of the community face individually and collectively. It is responsible for helping to prevent workplace and traffic misfortunes and for granting injured persons comprehensive medical, hospital, and rehabilitative services”*. (Emphasis not in the original). Meanwhile, Article 13 reads as follows: *“Health establishments shall be articulated with each other in service delivery networks according to levels of care, capable of offering universal coverage with services at the first level of care and staggered access to levels of greater complexity, as appropriate to the user’s need”*. For this Tribunal, it is clear that at the time of the counter-referral from Hospital San Juan de Dios to the INS, as subsequently occurred starting on May 31, 2012, what the plaintiff required was a surgical intervention to correct his hip fracture, even with the procedure performed by the INS or as a consequence thereof, this based on reasons, among others, of a medical nature, the ideal being that he be treated by the same physician who performed the procedure that failed to consolidate the hip fracture, as that professional was best placed to determine what complications might have arisen in the patient. Finally, pursuant to Article 42 of the same regulatory body: *“The* **basic** *functions of Hospitals are the following: (...) 3) Coordinate activities with centers of greater and lesser complexity within the health services network and with committees representing the communities”*. Thus, it is established that a duty of coordination is in any case imposed on the INS, not to leave one of its patients to their fate in the face of a referral to another medical center, especially under the plaintiff’s circumstances and, moreover, on the occasion of being counter-referred for medical and liability reasons in that sense. From an ethical—if not deontological—standpoint, the Code of Medical Morals (Código de Moral Médica), Executive Decree No. 35332 of May 15, 2009, imposes on the professional in its Article 22 that: *“...* **must not abandon their responsibilities toward their patient***, even temporarily,* **without leaving another qualified and informed physician to substitute them in the care of the former***, except on grounds of fully proven force majeure”*. This speaks of the possibility of being relieved of a patient’s care, to transfer them to another professional. This is applicable to the specific case, since the plaintiff is referred to a medical center that sends him back for medical reasons that were not investigated, only to then reject his care, it is insisted, not for medical reasons, but for contractual ones of a nature different from the science at hand. In any case, Article 34: *“Regardless of where the practice of the profession is carried out, the interests and integrity of the patient must be respected”*. Article 36: *“The physician, from the moment they have been called to give their care to a sick person and have accepted, is obliged to immediately ensure all medical care within their power, personally, or with the help of qualified third parties”*. Article 42: *“The physician must provide all pertinent information to the patient, at the time of transferring them for purposes of* **continuity of treatment***, when ending the physician-patient relationship, or if the patient requests it”*. (Emphasis not in the original). Finally, Article 63: *“The relations of the physician* **with other professionals and support staff in the health area***,* *must be based on mutual respect, on the professional or labor freedom and independence of each one,* **always seeking common interests for the well-being of the patient***”*. (Emphasis not in the original). Thus, the legal system imposes not being indifferent to a counter-referral such as that given to the plaintiff by Hospital San Juan de Dios, whether the criteria of its medical staff are correct or not. At the very least, the plaintiff should have been attended to in order to evaluate him and thereby determine whether or not it was the INS’s responsibility to correct a treatment or procedure poorly executed in its entirety, for which it was responsible to the patient. In such a case, should the INS be found responsible, whether or not his policy is exhausted, there is no doubt that the duty to correct the patient’s problem prevails if he so requires or claims it, at no cost due to issues of medical responsibility (responsabilidad médica), as warned by the physicians of the CCSS. This Tribunal observes that the actions taken also disregarded the Law on the Rights and Duties of Users of Public and Private Health Services (Ley sobre derechos y deberes de las personas usuarias de los servicios de salud públicos y privados), No. 8239, Article 2, subsection e), which provides as a right of these users to receive care efficiently and diligently. Article 50 of the General Health Law (Ley General de Salud) states that: *“Professionals or persons authorized to practice in health sciences responsible, by reason of their profession, for the technical or scientific direction of any medical care establishment, pharmacy, and the like, shall be jointly and severally liable with the owner of said establishment for the legal or regulatory infractions committed in said establishment”*, which to some degree reinforces the actions, in the terms already stated, of the medical professionals who counter-referred the plaintiff from Hospital San Juan de Dios to the INS, and correspondingly would have imposed on the Institute at least the duty to evaluate the plaintiff to determine his fate. Another matter is that, as noted, the CCSS, knowing the INS’s position, insisted on its position to the detriment of the affected party’s interests. Account should have been taken, according to the statements of Dr. Javier Francisco Soto Fallas, of the rationally acceptable notion that the suitable professional to determine the plaintiff’s health conditions and the treatment to be followed is the treating physician, in this case, the one who performed the procedure, as they best know what they did and can thereby establish what health services the system user is entitled to, based on a relationship that should exist between the scientific knowledge the professional possesses and the patient’s clinical history. We understand from this perspective that an entity that is part of the National Health System (Sistema Nacional de Salud), in this case the INS, cannot deny a medical service under the circumstances in which the plaintiff found himself, alleging exclusively that there is no longer policy coverage, or that the matter is not included in its benefits plan, when, on the contrary, in cases such as the present one, it is the entity’s duty to have all the elements from a medical point of view that are necessary to adequately support the decision to authorize or not the service to the patient, which it did not do. We add to the above that even in the matter before us, a responsible party is one who has the legal duty to repair damage, even if they did not cause it directly or materially, which is fully applicable to cases of medical responsibility (responsabilidad médica) insofar as it involves, among other facets, the obligation that physicians have to repair and satisfy the consequences of acts, omissions, and voluntary or even involuntary errors, within certain limits of course, contained in the exercise of their profession. In insurance matters regarding the INS, we also have that insurance splits into two aspects, being able, on one hand, to tend to repair the damage caused and nothing more, or, as the case may be, to take charge of the patient’s or user’s treatment; here the application of regulations different from those governing the insurance market and its products ensues. In the case of medical activity, all those directly or indirectly involved in the occurrence of the damage are responsible, such as the physician, the clinic or hospital, the auxiliaries, and the insurers, so a medical center cannot claim protection on the basis that, as a business organization, the same deontological rules that govern its professionals are not applicable to it. Having said the above, it is the criterion of this Tribunal that while it may not have been imposed by the legal system that the INS correct the failures of the procedure it performed on the plaintiff, it was imposed that it had to rule out its responsibility based on the information contained in the counter-referral given to the plaintiff by the physicians of Hospital San Juan de Dios, which imposed on it at least the duty to have evaluated him. Due to its actions, and as it was in reality, the plaintiff’s situation, insofar as he did not receive care at either of the two hospitals, was unjustifiably prolonged as a barrier to accessing the health services to which he was entitled in a timely manner, in the face of a condition that has the potential to affect any person’s quality of life due to how incapacitating, as well as painful, the suffered injury was, whereby the INS contributed with its conduct to the moral harm (daño moral) experienced by Mr. Badilla Castro, a situation that allows attributing the claimed liability to it, albeit more autonomously as was the case for the CCSS and for different reasons as we have set forth, it being unacceptable that exclusively under the protection of the Traffic Law (Ley de Tránsito) and the coverage of the plaintiff’s insurance, it was legitimized to have acted in the manner it did. The conduct thus displayed constitutes an anomaly in the provision of health services, which generated harm of the same subjective moral (moral subjetivo) type for which liability was attributed to the CCSS; however, given the participation in the facts by this state enterprise, it is estimated that the reproach or attribution to be made against the INS is lesser, and therefore it is estimated that the subjective moral harm (daño moral subjetivo) should be compensated in the sum of five million colones, and the corresponding order is so issued, on the basis of that amount being deemed adequate. As a separate note, this Tribunal cannot miss the opportunity to refer to an aspect of the care given to the plaintiff, which is considered necessary for the medical authorities of the INS to review. We consider that the patient must be adequately informed, and with the precision possible given their state and the projection of the care they will receive from the INS medical staff, at what point their policy will be exhausted and what the consequences thereof will be, so that they have the opportunity to decide, in an informed manner, whether they would prefer to be treated at another care center. It is not observed that this is currently occurring, at least based on the case under study, so the defendant Institute is urged to take note of this observation for present and future occasions.- **7.- Regarding the inadmissibility of the indemnity-related claims for the alleged absence of temporary disability benefit (subsidio de incapacidad), and for expenses associated with the purchase of medicines.** In a manner that is confusing in itself, the plaintiff petitioned the following as a claim for damages and/or losses against both defendant entities, jointly and severally: *“1. For the damage caused by the forty-five day period without attention to my health, during which I found myself completely deprived of medical assistance and the lack of benefit (subsidio) and temporary disability (incapacidad) during that time, for an amount of six hundred seventy-two thousand four hundred thirty-three colones and sixty-five céntimos”*. From the claimed damage, it is barely possible to identify that constituted by the lack of benefit (subsidio) and temporary disability (incapacidad) —we must understand— that he would have suffered during the time in which he would not have been treated by either of the defendant parties, with both refusing to provide care to the patient. That being the case, in what is not identified as damage, no analysis will be carried out in that regard, this tribunal not being mandated to speculate when, on the contrary, it is the party’s responsibility to be clear in what they petition. On the other hand, regarding the vaguely stated benefit (subsidio) and temporary disability (incapacidad), as well as the claim for medical expenses to be paid based on invoices, the majority of which do not identify the purchaser of various pharmaceutical products, suffice it to indicate that the claim is dismissed, on the ground that the plaintiff did not prove that, having required the supply of medicines from the CCSS within the period that elapsed from April 17 to May 31, both in 2012, they were denied to him, nor that in the same manner, temporary disability periods (incapacidades) or the delivery of the respective benefit (subsidio) were denied to him, all in the absence of evidence allowing the assertion of the contrary. Moreover, although mistreatment of the plaintiff by Hospital San Juan de Dios staff was mentioned, it is not found among his claims that any recognition for that alleged reproach, besides, is being sought, so no analysis will be conducted in that regard.- **VIII.- Corollary.** The plaintiff only partially proved the prerequisites that, according to the legal system, make the charges of liability (responsabilidad) formulated against the defendant entities admissible, in the terms set forth in this judgment. In what was not proven, the claim must therefore be dismissed, that is, regarding the alleged damage identified or associated with the absence of benefit (subsidio) and temporary disability (incapacidad), as well as the payment for expenses —invoices— that he accused having incurred due to the conduct displayed by the defendants. In what was found admissible, given that both defendant entities illegitimately affected the plaintiff’s right to health and access to medical services, they are autonomously condemned: the Costa Rican Social Security Fund (Caja Costarricense del Seguro Social), to pay the sum of fifteen million colones, and the National Insurance Institute (Instituto Nacional de Seguros), to pay the sum of five million colones, in both cases as compensation for the moral harm (daño moral) caused, all effective as of the finality of this judgment.-“

“VII.- Sobre la procedencia parcial de la demanda. Estima este Tribunal que se impone declarar con lugar la presente demanda en lo que fue incoada en contra de ambas partes demandadas y en función de las siguientes consideraciones:

1.- Sobre el régimen de responsabilidad civil extracontractual de la administración pública. Siempre que nos encontremos en torno con las partes en litigio ante la determinación de una eventual responsabilidad patrimonial de la Administración Pública, si la relación jurídica que vincula al administrado con la administración accionada no emerge con ocasión de la existencia de un instrumento contractual, se tiene que la discusión gira al rededor de lo que se conoce como responsabilidad civil extracontractual, por lo que resulta necesario a modo de introducción a los efectos de este instrumento, hacer referencia a los elementos que en doctrina y jurisprudencia suponen potable un reproche de responsabilidad como el que aquí se peticiona . Dentro del régimen de la llamada responsabilidad civil extracontractual, se distinguen dos tipos, la subjetiva, establecida en el artículo 1045 del Código Civil y la objetiva normada en el numeral 9 de la Constitución Política, el artículo 1048 del Código Civil y el numeral 190 y siguientes de la Ley General de la Administración Pública. En lo que toca al régimen de responsabilidad subjetiva, el artículo 199 de la Ley General de la Administración Pública establece la responsabilidad de los servidores públicos ante terceros en caso comprobado de dolo o culpa grave en el desempeño de sus deberes o con ocasión su cumplimiento. Como tal, la responsabilidad subjetiva se funda exclusivamente en un estudio en el ámbito del ánimo del agente respecto de la existencia de al menos, "culpa", sino "dolo", a diferencia de lo que ocurre con el régimen de responsabilidad objetiva, en orden al cual, la responsabilidad se determina con independencia de la existencia de tales elementos subjetivos. En la responsabilidad subjetiva se responde porque se es culpable, bien porque se ha buscado o querido la producción del daño, o bien porque se ha obrado de forma imprudente o negligente. En observancia con lo anterior, la responsabilidad del servidor ante terceros lo es en el ámbito del régimen de responsabilidad subjetiva, consecuentemente con lo cual, se requerirá para todos los efectos de la determinación de la existencia de culpa o dolo en el ánimo del servidor o agente de la Administración, sin perjuicio del resto de elementos que deben concurrir, como lo son la existencia del daño y el nexo causal entre aquel y la conducta desplegada, para que opere el reproche de imputación de responsabilidad. Por otra parte, el régimen de responsabilidad objetiva de la Administración Pública, a diferencia de lo que ocurre con la responsabilidad subjetiva, se genera sin que sea necesario demostrar el dolo o la culpa del agente causante del daño, bastando con la acreditación eso sí, de la existencia del "riesgo" para generarla, razón por la cual no operan las nociones de antijuridicidad y culpabilidad, por lo tanto, se aplica el principio de inversión de la carga de la prueba en beneficio del lesionado. A los efectos, la presunta Administración Pública causante de los daños y perjuicios reclamados debe resarcirlos si efectiva y eficazmente su conducta los generó, salvo que demuestre alguna causal exonerativa, sin perjuicio de que como condición insalvable en efecto se reitera, el efecto dañoso haya constituya la causa del despliegue de su actividad. De este modo, se requiere de la concurrencia de cuatro elementos, a saber: a) Una lesión, que consiste en los perjuicios patrimoniales antijurídicos, porque el que los padece no tiene el deber de soportarlos; b) Una conducta administrativa en relación con la cual se encuentre vinculada la producción del daño reprochado; b) Un nexo causal, conformado por la existencia de una relación directa de causa a efecto entre el hecho (conducta administrativa) que se imputa y el daño producido; y c) Que no existan las causas de justificación a que hicimos referencia atrás, siendo que la existencia de las mismas puede desvincular jurídicamente el perjuicio producido con la conducta de la Administración Pública, de modo talque el efecto dañoso no le sea imputable, rompiendo el nexo de causalidad al acontecer una situación eximente como la fuerza mayor , la culpa de la víctima y el hecho de un tercero. El régimen de responsabilidad patrimonial del Estado y sus instituciones previsto en los artículos 9, y 41 de la Constitución Política, y 190 y siguientes de la Ley General de la Administración Pública, es entonces de naturaleza esencialmente objetiva, por lo que para nacer basta con que exista un daño indemnizable, una conducta administrativa y un nexo causal entre ambas. Debe tenerse que es bajo este tipo de criterio objetivo que resulta posible atribuir responsabilidad a la Administración Pública, a diferencia de lo que ocurre con sus servidores, para los cuales debe de usarse un criterio de atribución además, subjetivo. De otra parte, determinados los criterios bajo los que es procedente establecer la responsabilidad de la Administración Pública y/o de sus agentes o servidores públicos, nos interesa señalar que a la vez, existe una diferencia en cuanto a los criterios de imputación que operan para el establecimiento o determinación de dicha responsabilidad en caso de encontrarnos ante actividad lícita o ilícita, normal o anormal de la Administración. Citando al Dr. Ernesto Jinesta Lobo, de su Obra Tratado de Derecho Administrativo II, Responsabilidad Administrativa, pág. 39, se tiene que: “En el sistema de responsabilidad sin falta o por sacrificio especial, responsabilidad por conducta lícita o funcionamiento normal, el criterio determinante para que exista responsabilidad de las administraciones públicas es el quebranto del principio de igualdad en el sometimiento de las cargas públicas y el consiguiente daño especial (pequeña proporción de afectados) y anormal (excepcionalidad intensa de la lesión) o la teoría del riesgo para la hipótesis de los daños accidentales causados por una administración pública en el cumplimiento de la función asignada por el ordenamiento jurídico. Tratándose del sistema de responsabilidad por falta de servicio,-conducta ilícita o funcionamiento anormal,- el criterio de imputación lo constituye, precisamente, ese concepto jurídico indeterminado de “falta deservicio”y el derecho constitucional innominado o atípico de los administrados a que les presten servicios públicos eficientes y eficaces.”. En la responsabilidad por conducta ilícita o anormal, entendida como aquella que se opone, infringe o violenta el ordenamiento jurídico entendido globalmente como las normas escritas y no escritas, la carga de la prueba corresponde a la víctima, quien corre con el deber de demostrar mediante las formas, los medios probatorios que permite el ordenamiento jurídico, la falta del servicio, su funcionamiento anormal, o la ilicitud en el actuar administrativo. En la responsabilidad por conducta lícita, se ha establecido que aun tratándose de conductas desplegadas con apego al ordenamiento jurídico, las mismas son susceptibles de de atribuir responsabilidad en la Administración bajo criterios como los relacionados supra. En los casos de responsabilidad objetiva, la defensa de la Administración radicaría en la demostración de haber mediado alguna de las causales que rompen el nexo de causalidad que indica el numeral 190, párrafo 1 de la Ley General de Administración Pública, ya sea como se indicó supra, la fuerza mayor, le hecho de un tercero o hecho de la propia víctima. Nuestra Sala Primera de la Corte Suprema de Justicia en resolución Nº 000584-F-2005, de las 10:40 hrs. del 11 de agosto del 2005, indicó, y siempre en relación con la responsabilidad objetiva lo siguiente: "...habrá responsabilidad de la Administración siempre que su funcionamiento normal o anormal, cause un daño que la víctima no tenga el deber de soportar, ya sea patrimonial o extrapatrimonial, con independencia de su situación jurídica subjetiva y la titularidad o condición de poder que ostente, cumpliendo claro está, con el presupuesto imprescindible del nexo causal. (...) Tanto los presupuestos esenciales como la carga de la prueba, adquieren por ejemplo un nuevo matiz, que libera al afectado no solo de amarras sustanciales sino también procesales, y coloca a la Administración en la obligada descarga frente a los cargos y hechos que se le imputan. En todo caso, el carácter objetivo de la responsabilidad civil extracontractual de la Administración, fue definida con claridad en la sentencia de esta Sala N° 132 de las 15 horas del 14 de agosto de 1991, para un hecho posterior a la entrada en vigencia de la Ley General de la Administración Pública, en la que dijo: "VI. Nuestra Ley General de la Administración Pública Nº 6227 (...), conforme lo señala la sentencia de esta Sala Nº 81 del año 1984, al resolver la polémica sobre su vigencia, en el Título Sétimo del Libro Primero, recogió los principios más modernos fundados en la doctrina y jurisprudencia más autorizada, sobre la responsabilidad extracontractual de la Administración, para establecer así la responsabilidad directa del Estado sin necesidad de probar previamente que el daño se produjo por culpa del funcionario o de la Administración, exigiendo para la procedencia de la indemnización que el daño sufrido sea efectivo, evaluable e individualizable en relación con una persona o grupo -artículo 196-. (...) Además establece, en forma taxativa, como causas eximentes de esa responsabilidad, la fuerza mayor, la culpa de la víctima y el hecho de un tercero, correspondiéndole a la Administración acreditar su existencia , (...)" (El resaltado no es del original). En lo particular, referente a la eventual responsabilidad de una entidad como la Caja Costarricense del Seguro Social asociada a la prestación de los servicios de salud que se encuentran bajo su cargo, la Sala Primera de la Corte en su Voto Nº 7 de las 14:20 hrs. del 13 de enero de 1995, también ha indicado como sigue: "(...) Es esta teoría de responsabilidad objetiva la que requiere que con el riesgo creado se ocasione un daño al administrado susceptible de indemnización, (...). V)- Para restablecer la responsabilidad de la Caja Costarricense de Seguro Social ha de reconocerse el nexo causal entre el daño provocado al actor y la actuación de dicha entidad, o sea, entre el acto impugnado y el evento lesivo. (...) La relación causal entre el hecho (actividad que consistió en prestarle servicios médicos) y el efecto (...) es clara, ineludible y referible estrictamente a la institución demandada. No amerita hacer reparo en que el paciente fuera o no hipersensible al medicamento indicado, sino solamente -como lo afirmó el perito ( ...)- que se creó un riesgo que, como excepción a la resistencia común de los organismos- provocó un daño en el paciente y éste no tiene por qué soportarlo sin -al menos- ser indemnizado por ello . En síntesis, el riesgo lo creó la Caja Costarricense de Seguro Social, a través de sus hospitales, ocasionando daño al paciente hoy actor y, en consecuencia, con fundamento en la ya mencionada teoría del riesgo, debe responsabilizársele por su actuación. (El resaltado no es del original). En consecuencia y de manera concordante con todo lo anterior, se haría estéril la determinación de la existencia del daño que se reclama, si identificado éste por el accionante y no se acreditada la conducta administrativa reprochada -en este caso la realización procedimientos médicos que no den con un adecuado y oportuno diagnóstico del mal que padece el paciente- pues de entrada, no se lograría al menos determinar, que con vínculo en el servicio médico que se le prestó al accionante, medió un nexo causal que permita concluir que fue ese procedimiento y no otra circunstancia, el que objetiva y eficazmente, constituyó la génesis u origen del daño reprochado.- 2.- Sobre el derecho a la salud y acceso a los servicios médicos. El derecho a la salud constituye un derecho fundamental consagrado en la Constitución Política, si se relacionan sus numerales 21 y 50, (derecho a la vida así como a un ambiente saludable y ecológicamente equilibrado). De ello y en gran medida, su efectiva garantía proviene de un ejercicio prestacional, esto en razón de que son los servicios de salud dados a partir de los centros hospitalarios, entre otros, los que se dirigen de forma directa a la atención de afectaciones a la salud de la población en general. En consecuencia, el Estado o sus instituciones -entre las que se encuentra la Caja Costarricense del Seguro Social y en diferencia de grado, el Instituto Nacional de Seguros en lo que le corresponda conforme la ley- se encuentran mandados a adoptar todas las medidas o acciones necesarias y positivas para garantizar ese derecho de forma adecuada y razonable. No está por demás indicar que ambas instituciones entre otras -públicas y privadas- forman parte del que se ha denominado Sistema Nacional de Salud conforme el respectivo reglamento, artículos del 1 al 4, 9, 18 y 82, que fue publicado en el Diario Oficial “La Gaceta”número 230 del 05 de diciembre de 1989, Decreto Ejecutivo número 19276-S del 09/11/1989. Por otro lado se encuentran las reglas deontológicas que rigen el ejercicio de las artes asociadas a la ciencia de la salud y médica, así como aquellas dirigidas a la regulación de los centros hospitalarios propiamente dichos -públicos como privados-. La Sala Constitucional se ha encargado del dimensionamiento de este derecho y así, en su sentencia número 2010-07602 de las 14:49 horas del 27 de abril del 2010, indicó al respecto que: “La Organización Mundial de la Salud (OMS) en su Constitución -adoptada en Nueva York en 1946-, definió la salud como el estado de completo bienestar físico, mental, espiritual, emocional y social, y no solamente la ausencia de afecciones o enfermedades. Sobre el derecho a la salud, en un sentido amplio, es ilustrativo lo dispuesto por este Tribunal en el Voto No. 1915-92 de las 14:12 hrs. del 22 de julio de1992, que, en lo que interesa, señala lo siguiente: "(...) el derecho a la salud tiene como propósito fundamental hacer efectivo el derecho a la vida, porque éste no protege únicamente la existencia biológica de la persona, sino también los demás aspectos que de ella se derivan. Se dice con razón, que el ser humano es el único ser de la naturaleza con conducta teleológica, porque vive de acuerdo a sus ideas, fines y aspiraciones espirituales, en esa condición de ser cultural radica la explicación sobre la necesaria protección que, en un mundo civilizado, se le debe otorgar a su derecho a la vida en toda su extensión, en consecuencia a una vida sana. Si dentro de las extensiones que tiene éste derecho está, como se explicó, el derecho a la salud o de atención a la salud ello incluye el deber del Estado de garantizar la prevención y tratamiento de las enfermedades (...)". Igualmente, categórico es lo dispuesto por esta Sala en la Sentencia No. 11222-03 de las 17:48 hrs. del 30 de septiembre del 2003, al señalar lo siguiente: "(...) VI.- DERECHO FUNDAMENTAL A LA SALUD. El derecho a la vida reconocido en el numeral 21 de la Constitución es la piedra angular sobre la cual descansan el resto de los derechos fundamentales de los habitantes de la república. De igual forma, en ese ordinal de la carta política encuentra asidero el derecho a la salud, puesto que, la vida resulta inconcebible si no se le garantizan a la persona humana condiciones mínimas para un adecuado y armónico equilibrio psíquico, físico y ambiental (...)". De este modo habrá de recalzarse que el derecho fundamental enunciado se garantiza a través de acciones dirigidas a preservar la vida humana en condiciones mínimas que propicien un integral, adecuado y armónico equilibrio psíquico, físico y ambiental, todo lo cual claro está, resulta de aplicación directa a la operación de los centros hospitalarios, tanto como el ejercicio de la ciencia médica, entre otras actividades y ciencias, así como profesiones diversas, que en su ejercicio inciden en este tópico. Por lo demás, el derecho a la salud se encuentra reconocido a nivel del derecho internacional, artículo 25 de la Declaración Universal de Derechos Humanos; 7 y 1 de la Declaración Americana, 3, 6, 23 y 24 de la Convención de los Derechos del Niño. En consecuencia y sin perder de vista que el operador jurídico habrá de observar el principio de control de convencionalidad, tanto el derecho de la Constitución como todo aquel instrumento del derecho internacional que proteja con mayor potencia que ésta, un derecho de la especie, informarán la interpretación y aplicación del orden normativo infraconstitucional en la solución de problemas en casos concretos . Siendo de nuestro interés el tema vinculado con la prestación de servicios médicos, véase también lo indicado por la Sala Constitucional en su sentencia número 2011-003683 de las 15:47 horas del 22 de marzo del 2011, en la que se indicó lo siguiente: “Basta sólo con consultar el Pacto Internacional de Derechos Económicos, Sociales y Culturales, en su numeral 12, para percatarnos de lo que venimos afirmando. En efecto, en dicho instrumento internacional de derechos humanos se establece claramente el derecho de toda persona al disfrutar del más alto nivel posible de salud física y mental, por lo que el Estado y sus instituciones tienen el deber de asegurar la plena efectividad de ese derecho a través de una serie de acciones positivas y del ejercicio de las potestades de regulación, fiscalización y de policía sanitaria. Lo anterior significa, ni más ni menos, la prevención y el tratamiento efectivo de enfermedades, así como la creación de condiciones que aseguren a todos la asistencia médica y servicios médicos de calidad en caso de enfermedad. Dicho lo anterior, el derecho a la salud comprende la disponibilidad de servicios y programas de salud en cantidad suficiente para los usuarios de estos servicios y destinatarios de estos programas. Por otra parte, el derecho a la salud también conlleva la accesibilidad a estos servicios y programas, cuya cuatro dimensiones son la no discriminación en el acceso a los servicios de salud, la accesibilidad física -particularmente por parte de los más vulnerables-, la accesibilidad económica -que conlleva la equidad y el carácter asequible de los bienes y servicios sanitarios- y la accesibilidad a la información. No menos importante es que los servicios y programas de salud sean aceptables, es decir, respetuosos con la ética médica, culturalmente apropiados, dirigidos a la mejora de la salud de los pacientes, confidenciales, etc. Por último, y no por ello de menor relevancia, el derecho a la salud implica servicios y programas de calidad, lo que significa que tales servicios deben ser científica y médicamente apropiados”. Pues bien, teniéndose en cuenta lo anterior, será que procederemos al análisis de la procedencia o no de lo peticionado en la demanda que se conoce en los términos del presente instrumento.- 3.- Del seguro obligatorio para vehículos automotores. Estimamos oportuno por resultar sintético, pero integral al tiempo, hacer cita de lo enunciado al respecto por parte de la Sección VIII de este Tribunal en su sentencia 110 - 2013 de las 15:00 horas del 28 de noviembre del 2013, oportunidad en la cual sobre este tema se señaló lo siguiente: “IV.- (...) El denominado Seguro Obligatorio de Automóviles corresponde a un instrumento de tutela y soporte económico (concretado contractualmente entre el propietario de un vehículo y una aseguradora pública o privada) para los posibles afectados en un accidente de tránsito, que es impuesto por el ordenamiento jurídico a los propietarios de vehículos como requisito autorizante para su desplazamiento en el territorio nacional. Por su medio, los conductores, pasajeros y terceros -transeúntes o viajeros - son cubiertos en relación con el riesgo que genera la actividad de conducción de un automotor, la que eventual puede causar el fallecimiento de ciudadanos, o bien, su incapacidad total o parcial, así como gastos médicos, hospitalarios y de rehabilitación, viáticos, alimentación u otros supuestos -según los parámetros del seguro -, cubiertos a través de subsidios, en caso de un accidente de tránsito. Ciertamente lleva implícito un interés público que, debe aclararse, no implica una transmutación de dicho mecanismo en un seguro de carácter social, pues el deber de su adquisición está vinculada y direccionada a la propiedad de un vehículo y, por consiguiente, quien lo tome, establecerá un nexo contractual privado con la entidad aseguradora que brinde el servicio. En esa línea, debe resaltarse, el límite del quantum de los subsidios que eventualmente sean otorgados, queda supeditado, por una parte, al tipo y grado de las lesiones causadas y, por otra, a la suma pactada entre el particular-asegurado y empresa aseguradora que, por lo general, está definido en una cláusula de adhesión del contrato, la que varía cada cierto período . Paralelamente, ese seguro conlleva un elemento de protección del patrimonio del propietario del vehículo (o de su conductor) responsable de la lesión, quien intempestivamente puede llegar a enfrentar una tensión de naturaleza económica ante la provocación impensada de una lesión, por lo que el SOA funciona también como un medio de compensación o equilibrio del patrimonio del causante del daño, pese a que, eventualmente, esa responsabilidad pueda superar la cobertura pactada, en cuyo caso, satisfecho el monto del seguro, la entidad aseguradora se desvincula del asunto, quedando directamente obligado el generador del detrimento por imperativo constitucional (numeral 41 de la Carta Magna), lo que ya fue abordado indirectamente en lo que refiere a los seguros obligatorios por la Sala Primera de la Corte Suprema de Justicia mediante voto Nº 30-F-2005 de 10:45 horas de 27 de enero del 2005. Desde una óptica normativa, el SOA tiene origen en la Ley de Tránsito, verbigracia, Nº 5322 de 27 de agosto de 1973, derogada por la Ley Nº 5930 de 13 de septiembre de 1976, que a su vez fue substituida por la Ley de Tránsito por las Vías Públicas Terrestres, Nº 7331 de 13 abril de 1993 y sus subsiguientes reformas. Para la fecha en que tuvo lugar el accidente origen de este proceso, el monto del seguro estaba determinado en tres millones de colones, y era de aplicación la Ley Nº 8696 de 17 de diciembre del 2008, así como el Reglamento sobre el Seguro Obligatorio para Vehículos Automotores Nº 25.370-MOPT-J-MP de 04 de julio de 1996. En forma general, se procede a hacer referencia a las bases legales de trascendencia para este tipo de seguro. Así, el ordinal 39 de la Ley establece la obligatoriedad de dicho instrumento, brindando a la vez el sustento para la emisión de la regulación reglamentaria. El numeral 49 reza de manera expresa: "El seguro obligatorio de los vehículos cubre la lesión y la muerte de las personas, víctimas de un accidente de tránsito, exista o no responsabilidad subjetiva del conductor. Así mismo, cubre los accidentes producidos con responsabilidad civil, derivados de la posesión, uso o mantenimiento del vehículo. En este último caso, esta responsabilidad debe ser fijada mediante los procedimientos establecidos y ante los tribunales competentes."Por su parte los ordinales 52 y 53 definen los límites y las prestaciones económicas procedentes y, el 51, indica que el límite máximo de cobertura del seguro obligatorio de vehículos estará definido por el reglamento a la Ley, el cual, es determinado por el artículo 14 ...”. (El resaltado no es del original). Debe llamarse la atención en que el Instituto Nacional de Seguros en lo que administra este seguro y al tiempo, preste directamente servicios de salud a través de su centro hospitalario, ejerce funciones que se desdoblan en cuanto a su regulación, siendo la primera de orden comercial al tenor de una actividad económica ordinaria y principal -hoy liberalizada en el marco del mercado de seguros- y por otro lado, una prestacional en materia de la prestación de servicios hospitalarios, que asociados o no a la cobertura de una póliza de seguro, corresponde con actividad regida por normativa especial , así informada por las reglas de las artes asociadas a la ciencia médica y en esta última medida, a las reglas deontológicas que rigen el actuar médico a través de los profesionales en esa área a través de los que actúa un nosocomio.- 4.- Sobre la naturaleza de los servicios prestados por el Instituto Nacional de seguros. No obstante este tópico pareciera ser pacífico, por su relevancia para el dictado del presente fallo habrá de retomarse. Un cuerpo normativo especial en la materia por primera vez implementado puede ubicarse a partir del mes del dos de octubre de mil novecientos veintidós con la Ley de Seguros número 11, publicada en la Colección de Leyes y Decretos correspondiente de ese año, segundo semestre, tomo primero, página 314, en momentos en que se encontraba liberalizada a la libre competencia la actividad vinculada con la posibilidad de aceptar mercantilmente a cambio de la satisfacción de una prima, la transferencia de los riesgos a los que siendo asegurables, se encuentren circunstancia que prevista que así lo justifique, se haga dispensable una indemnización que cubra la carga económica que pueda generar tal evento, por los efectos nocivos en el patrimonio del asegurado y/o su integridad personal. El día treinta de octubre de mil novecientos veinticuatro se promulga la Ley número 12 de esa data, hoy, Ley del Instituto Nacional de Seguros, mediante la que se derogó en un todo la anterior Ley de Seguros. Se creó a través de esta una entidad con la denominación de Banco Nacional de Seguros , que posteriormente mutaría a instituto. La creación de esta organización se produjo conforme los numerales 4 y 5 de dicha ley, previéndose desde entonces la futura monopolización del mercado, siendo diseñada en tanto, para que el Banco Nacional de Seguros sirviese para contratar y realizar los seguros del Estado. Luego, en el artículo 5 de este cuerpo normativo, se creó el Instituto Nacional de Seguros a partir de la reforma operada por la Ley número 4183 del cuatro de septiembre de mil novecientos sesenta y ocho, que relacionada con la reforma sobreviniente operada por la ley número 6082 del treinta de agosto de mil novecientos setenta y siete y la Ley 6082 del mismo año, terminan estableciendo que el monopolio estatal, que generó que esta actividad se encontrara exclusivamente bajo la administración de dicho instituto, operando este como entidad autónoma. En la actualidad la Ley del Instituto Nacional de Seguros se encuentra vigente conforme el texto de su ley constitutiva, una vez reformada conforme el artículo 52 de la Ley Reguladora del Mercado de Seguros, número 8653 del veintidós de julio de dos mil ocho, publicada en el Diario Oficial “La Gaceta”número 152, alcance 3, del siete de agosto del mismo año. Esta reforma devino como consecuencia de las obligaciones adquiridas por el Estado con sus homólogos en lo conducente , con ocasión de la adopción del Tratado de Libre Comercio , Estados Unidos, Centroamérica y República Dominicana, aprobado por la Ley número 8622 del veintiuno de noviembre del dos mi siete, publicada en el Diario Oficial “La Gaceta”número 246, del veintiuno de diciembre de ese mismo año, alcance 40. Los compromisos derivados que resultan de interés ser ubican dentro del anexo del tratado correspondiente a servicios financieros y en materia de seguros. (Ver artículo 7 constitucional). Así, el artículo primero de la Ley del Instituto Nacional de Seguros, reformado por la Ley Reguladora del Mercado de Seguros, dispuso en lo conducente como sigue: “El Instituto Nacional de Seguros, en adelante INS, es la institución autónoma aseguradora del Estado, con personalidad jurídica y patrimonio propios, autorizada para desarrollar la actividad aseguradora y reaseguradora. En dichas actividades le será aplicable la regulación, la supervisión y el régimen sancionatorio dispuesto para todas las entidades aseguradoras. / (...). / En el desarrollo de la actividad aseguradora en el país, que incluye la administración de los seguros comerciales, la administración del Seguro de Riesgos del Trabajo y del Seguro Obligatorio de Vehículos Automotores, el INS contará con plena garantía del Estado. / El INS queda facultado para constituir o adquirir participaciones de capital en sociedades anónimas, sociedades comerciales, sucursales, agencias o cualquier otro ente comercial de naturaleza similar, ninguno de los cuales contará con la garantía indicada en el párrafo anterior para los siguientes propósitos: a) Ejercer las actividades que le han sido encomendadas por ley dentro del país. Dichas actividades comprenden las de carácter financiero, otorgamiento de créditos, las de prestación de servicios de salud y las propias del Cuerpo de Bomberos, el suministro de prestaciones médicas y la venta de bienes adquiridos por el INS en razón de sus actividades. / Adicionalmente, el INS podrá establecer, por sí o por medio de sus sociedades, alianzas estratégicas con entes públicos o privados en el país o en el extranjero, con la única finalidad de cumplir con su competencia. / Tanto el INS como sus sociedades anónimas, con la aprobación de las respectivas juntas directivas, podrán endeudarse en forma prudente de acuerdo con los estudios financieros correspondientes. Estas operaciones no contarán con la garantía del Estado. / Se autoriza a los bancos públicos a participar como accionistas de las sociedades anónimas que el INS establezca según lo señalado en este artículo, siempre que el INS se mantenga como socio mayoritario de dichas sociedades “. El texto como se indicó, corresponde con el momento histórico en el que producto de los alcances del tratado de libre comercio mencionado se rompe con el monopolio existente y se abre completamente al mercado de seguros en todas sus manifestaciones a la libre competencia los productos asociados al aseguramiento. De entrada el artículo primero indicado corresponde con una línea legislativa orientada con potencia a reforzar la capacidad del Instituto de actuar bajo el régimen de derecho privado a efecto de que siendo de interés público su actividad, se dirija a una exitosa participación en el libre mercado de productos asociados a la actividad aseguradora, como parte del sector productivo estatal. La actividad medular o epicéntrica del Instituto lo es conforme su ley constitutiva la comercialización de productos de seguros, no obstante, también lo han sido otras como las actividades financieras asociadas, y otra ajena a esta específica actividad mercantil principal en el marco de un mercado liberalizado, que se conserva residualmente -habría que decir - como producto de aquellos momentos en que la actividad se encontraba bajo el monopolio estatal por su medio, como lo es la actividad desplegada por el Cuerpo de Bomberos, que antes de la reforma provocada con ocasión de la misma Ley Reguladora del Mercado de Seguros, se erigía como órgano con desconcentración mínima. Hoy, se trata de un órgano con personería jurídica instrumental y desconcentración máxima, adscrito al Instituto según Ley del Benemérito Cuerpo de Bomberos número 8338 del 19 de marzo del 2002, artículos 1 y 2. Por otro lado se encuentran las actividades vinculadas con las prestaciones médicas, que se encuentran originadas en vínculo directo con la actividad aseguradora, de modo que se trata de servicios médicos a través de centros hospitalarios propios o de terceros con quienes se vincule al efecto, que en ambos casos corresponden con un servicio de corte privado sujeto a la existencia de un contrato de seguros, comercializable por cualquier aseguradora autorizada, diversos a aquellos que habrían de entenderse se encuentran comprendidos dentro de los servicios de la seguridad social administrados por la Caja Costarricense del Seguro Social, éstos últimos respecto de los que sí se puede afirmar su naturaleza de servicio abierto al público de forma universal. Estos servicios médicos prestados por el Instituto, como podrían serlo por parte de cualquier tercero autorizado se insiste, con claridad corresponden con los efectos y alcances de los servicios asociados como prestación a algunos de sus productos, como lo son los seguros denominados personales. De esto algo adelantó el constituyente, a partir del contenido que fue dado al artículo 73 de la Carta Magna, al determinar con un régimen especial a ser desarrollado por el legislador ordinario y diverso al correspondiente a los seguros sociales para el caso de los seguros obligatorios para riesgos del trabajo, erigidos con la finalidad de proteger a los trabajadores con carga en su patrono sirviendo de mecanismo para el acceso a servicios de salud. Se trata de un seguro que obra como obligación exclusiva de los patronos frente a los trabajadores con quienes se vincule, sea, con carga en su patrimonio exclusivamente y conforme lo determine así la normativa correspondiente. Con causa en ello, el patrono debe obligatoriamente adquirir dentro del mercado, el producto de seguros correspondiente a fin de dar cumplimiento con esta disposición, como también es obligatorio para los propietarios de vehículos automotores, pagar a efecto de acceder al derecho de circulación, el seguro obligatorio correspondiente, que habría de cubrir en lo medular, la muerte y/o la atención de las lesiones producidas con causa en un accidente de tránsito. Actualmente la Ley Reguladora del Mercado de Seguros, que como efecto del Tratado de Libre comercio apuntado arriba propició la apertura del mercado al grado tal que fueron incluidos tanto los seguros obligatorios de vehículos automotores, como los de riesgos del trabajo en los términos de lo dispuesto en el transitorio III de esa ley, relacionado con su artículo 2, último párrafo, quedando exceptuados de la aplicación de esta normativa y por tanto, fuera del libre comercio, sólo los sistemas de seguridad social obligatorios administrados por la Caja Costarricense de Seguro Social y los regímenes especiales de pensiones creados por ley y la póliza mutual obligatoria administrada por la Sociedad de Seguros de Vida del Magisterio Nacional, hablan de que no se trata de servicios de corte social con la apertura de los que presta la Caja Costarricense del Seguro Social, aquellos que presta el Instituto en materia de salud. Esta liberalización podía advertirse como potable conforme el derecho de la Constitución, desde que la Sala Constitucional en su sentencia número 2001-12952, de las dieciséis horas con veinticuatro minutos del dieciocho de diciembre del dos mil uno, afirmó como sigue: “II.- Los puntos segundo y tercero de la consulta están íntimamente ligados, en tanto parten de que el Instituto Nacional de Seguros tiene constitucionalmente asignada la competencia en materia de riesgos de trabajo, lo que es inexacto. El artículo 73 constitucional señala con claridad que “Los seguros contra riesgos profesionales serán de exclusiva cuenta de los patronos y se regirán por disposiciones especiales”, de lo que se concluye que es ley la encargada de desarrollarlos. El artículo 188 constitucional se limita a indicar que las aseguradoras del Estado son instituciones autónomas, y de esa disposición no puede válidamente concluirse que la Constitución le ha otorgado al INS competencia exclusiva en materia de riesgos del trabajo. El seguro de riesgos profesionales, como monopolio del Estado, tiene su origen en la Ley N° 12 del mes de octubre de 1924; por Ley n. 33 del 23 de diciembre de 1936 nació a la vida jurídica el Instituto Nacional de Seguros, al que se le mantuvo la competencia para comercializar, entre otros tipos de seguros, el de riesgos profesionales que nos ocupa. Posteriormente, el artículo 73 Constitucional estableció los seguros de riesgos profesionales “ por cuenta de los patronos “ dejando la regulación a la ley ordinaria, la que no ha sufrido modificación alguna y por ello el Instituto Nacional de Seguros ha mantenido a largo de los años esa competencia. La lectura de las Actas de la Asamblea Nacional Constituyente nos muestran con claridad que el artículo 73 fue redactado en una forma amplia para permitir, en el futuro, que en lo relacionado con los seguros de invalidez, vejez, muerte y riegos profesionales estuviera en una sola dirección, consiguientemente, no puede considerarse contrario al orden constitucional el establecimiento de coadyuvancia lógicas entre instituciones del Estado, para lo cual no hace falta cumplir con el trámite de audiencias que echan de menos los consultantes “. (El resaltado no es del original). Pues bien, de este tipo de organizaciones autónomas como lo son el Instituto demandado, dio cuenta el legislador al promulgar la Ley General de la Administración Pública número 6227 en mil novecientos setenta y ocho. Conforme sus artículos del 01 al 3, la Administración Pública a través de sus diversas manifestaciones orgánicas, cuenta con capacidad de derecho público y privado para actuar y luego, siendo el derecho público el que rige la actividad del Estado, si bien aplica también para otros entes públicos diversos a este como los descentralizados, lo es así siempre que no medie ley en sentido contrario. Por ello resulta posible que sea el derecho privado, el que regule determinada actividad de aquellos entes, cuando medie ley que así lo indique, cosa que puede bien darse con causa en que por su régimen de conjunto y los requerimientos de su giro, deban estimarse como empresas industriales o mercantiles comunes. Se encuentra reforzado lo anterior si se observa el contenido de los artículos 111 y 112 del mismo cuerpo legal en lo que regula las relaciones de servicio entre la Administración y sus agentes, cuando éstos estos no participan de lo que puede entenderse como gestión pública, o que participan en relación jurídica con empresas públicas o servicios económicos del Estado encargados de gestiones sometidas al derecho común. Por principio finalista de interpretación de las normas y sin perjuicio de posiciones ideológicas que en el pasado y presente maticen de modo diverso lo que se dirá, desde su existencia una vez promulgada la Ley General de la Administración Pública, luego, reforzado y calificado lo anterior a partir de la puesta en vigencia de la Ley Reguladora del Mercado de Valores, informadas estas últimas por los alcances del Tratado de Libre Comercio Estados Unidos, Centroamérica y República Dominicana, aprobado por la Ley número 8622, es claro que la naturaleza jurídica del Instituto Nacional de Seguros lo es el de empresa pública estatal, creada bajo forma de Derecho Público no obstante ello, creada para la prestación de servicios mercantiles regulados por el derecho común. La organización se encuentra ubicada en el marco de lo que se entiende dentro del sector productivo de la organización descentralizada institucional pública. Debe observarse el artículo 2 de la Ley del Instituto Nacional de Seguros en lo que indica así: “Aplicación del Derecho privado. Los actos que se generen a partir del desarrollo de su actividad comercial de seguros, actuando como empresa mercantil común, serán regulados por el Derecho privado, por lo que en el ejercicio de la actividad aseguradora, el Instituto quedará sometido a la competencia de los tribunales comunes”. De lo anterior como derivación, vista la actividad que legalmente despliega esta entidad, ninguna de sus manifestaciones es o constituye un servicio público, pues no comparten con aquel sus características, salvo el asociado con los de extinción de incendios, residenciado en un órgano persona que se encuentra adscrito al mismo, como lo es el Cuerpo de Bomberos, sin que esta particular actividad constituye en eje neurálgico de la entidad. Debe hacerse notar que aún e incluyendo la comercialización de los seguros obligatorios sobre automóviles o de riesgos de trabajo dentro de la actividad del Instituto, por interés social que puedan revestir éstos, son productos de seguros personales en el mercado de seguros que hoy pueden ser ofertados por cualquier participante autorizado, por lo que no guardan ninguna diferencia con el resto de los productos asociados a este mercado de seguros pasando a constituir bienes y servicios de corte mercantil en todas sus aristas. Esta afirmación se ve reforzada en el marco de una liberalización del mercado a la libre competencia en materia de seguros, dentro de la que el legislador además, ha apostado al reforzamiento de la capacidad de esta institución en el despliegue de su capacidad de actuar regida por el derecho privado, a fin de procurar su participación exitosa en un marco de igualdad en el mercado, frente a otros participantes del mismo, lo que se ha proyectado con potencia en su capacidad no solo de administrar la gestión de sus atribuciones y competencias, sino además, de auto organizarse a esos propósitos. El hecho de que el patrimonio que administre el Instituto constituya parte del haber de la hacienda pública, no dice nada que no opere para el resto de las empresas públicas estatales que como esta, ejercen una actividad mercantil sujeta al derecho privado, pero al tiempo, a ciertos controles que para cada institución pueden variar en diferencia de grado e intensidad. (Artículos 8 y 9 de la Ley Orgánica de la Contraloría General de la República). Pues bien, debiéndose tomar nota tal y como indicamos arriba, que asociado o no a la aplicación de un producto en el marco de la actividad aseguradora de corte mercantil, tanto en ese tanto la conducta desplegada frente al actor por parte del Instituto Nacional de Seguros, como la de la Caja Costarricense del Seguro Social, resultaron desajustadas con el ordenamiento jurídico, por lo que en materia prestacional constituyeron eso sí, en diverso nivel, conductas anormales que hacen potable lo demandado en parte como se verá, pues sirven de criterio de imputación de responsabilidad patrimonial con causa en que constituyeron además, el origen de un daño moral experimentado de forma intensa por el actor, que deber.- 5.- Sobre la procedencia parcial de la demanda en contra de la Caja Costarricense del Seguro Social. Este Tribunal considera apropiado iniciar este aparte relacionado lo que conforme los hechos que se han tenido por probados, es de relevancia para la resolución del punto en cuestión.

5.1.- En relación con este parte, se tiene que el día 08 de marzo del 2012 el señor Gilberto Badilla Castro sufrió un accidente de tránsito, producto del cual presentó lesiones que ameritaron su traslado a un hospital, en este caso, al Hospital San Juan de Dios. (Hecho no controvertido, en relación con el folio 108 del expediente clínico del Hospital San Juan de Dios, en su tomo I y el 120 del expediente clínico del INS, en su tomo I, así como el 65 y 36, del legajo de prueba del INS, tanto como el 10 del legajo de la medida cautelar, 85, 86 y 78 del principal). En ese nosocomio el actor fue atendido, se le dio atención primaria y se le estabilizó, para luego ser referido al INS, exclusivamente con causa en que fue de conocimiento institucional que se encontraba cubierto por una póliza, del seguro obligatorio para vehículos automotores. (Hecho no controvertido, en relación con el testimonio rendido en audiencia complementaria por parte del doctor Javier Francisco Soto Fallas). Punto aparte si ello correspondía o no, se trató de un hecho no controvertido, que además se encuentra soportado por la prueba que obra a folio 75 del expediente del legajo identificado como prueba del INS. Pues bien, efectivamente el actor se encontraba protegido por una póliza de la especie, pero habría de corresponder con una liberalidad de su parte el permanecer en ese centro médico a fin de que se le prestase atención médica -Hospital San Juan de Dios- o ser trasladado en su caso al INS, dado que la aplicación de la póliza mencionada, no sólo corresponde con un derecho que le compete exclusivamente a él y es disponible, sino que además, para el momento en que sufrió el accidente de tránsito se encontraba asegurado por su patrono de forma directa como trabajador asalariado ante la CCSS. (Hecho no controvertido, en relación con el folio 11 del legajo de la medida cautelar en que consta copia de la orden patronal vigente para el mes de la ocurrencia del accidente, así como el folio 79 del principal en que consta copia del carné que le acredita como asegurado directo). Sin perjuicio de que es claro que asegurado o no por el INS, el actor se encontraba asegurado al timepo por la CCSS, sobre el particular es conteste lo dispuesto en el artículo 23 del Reglamento sobre el Seguro Obligatorio para Vehículos Automotores, que reza así en lo conducente: “Las prestaciones sanitarias establecidas por este seguro comenzarán a brindarse por los médicos del Instituto Nacional de Seguros o los que éste designe o, bien, la víctima contrate en su condición de lesionada, pero en este último caso el costo de las prestaciones sanitarias que reconocerá dicho Instituto se sujetará, por su orden, a las tarifas vigentes para servicios similares que preste el Instituto, o en su defecto los de la Caja Costarricense de Seguro Social, y por último, los definidos en convenios suscritos entre el Instituto y los particulares, sin perjuicio de que el profesional o las víctimas, si fuere del caso, pudieren cobrar la diferencia al responsable del accidente”. Esto es, que el asegurado por el INS de todas maneras conserva el derecho de elegir por quién ser tratado, lo que no excluye la aplicación de su póliza, de manera que no se podría afirmar bajo el principio no jurídico de que quien puede lo más puede lo menos, que no pudiese elegir ser atendido por la CCSS, ya en aplicación del seguro obligatorio de vehículos automotores, ya por el simple hecho de ser asegurado ante dicha institución prestataria de servicios de salud. En esta línea de ideas, véase que el doctor Javier Francisco Soto Fallas, especialista del Hospital San Juan de Dios informó en juicio de que al ingresar un paciente con lesiones producidas por un accidente de tránsito, lo que suele hacerse con él es que se le pregunta si se encuentra cubierto por una póliza del seguro obligatorio de vehículos automotores o no, de forma que si indica que sí, se le refiere al INS, al parecer por automatismo. Debe agregarse que ninguna prueba obra en los expedientes administrativos de que el actor se le haya informado de sus derechos en este tanto, así como de que su remisión al INS, haya correspondido con su voluntad, aunque este aspecto no resulta medular para la resolución del presente asunto en la medida en que tampoco consta o se ha dicho de su parte, que se hubiese obrado contra su voluntad. Pues bien, referido que lo fue al INS por parte de las autoridades médicas del Hospital San Juan de Dios, el actor ingresó en a esa empresa estatal (INS Salud) el día 09 de marzo del 2012, en donde fue internado y se le brindó atención. El 12 de marzo del 2012, fue valorado en el servicio de ortopedia por parte del doctor identificado con el nombre de Max Rojas Badilla, (testigo del que en la presente causa, habiendo sido admitido como prueba, desistió la representación del INS en la audiencia de juicio) quien habría diagnosticado la presencia de una fractura en el cuello del fémur izquierdo transcervical de la cadera izquierda, requiriéndose cirugía, para lo que en un primer orden de ideas debía de hacerse retiro de un elemento asociado a osteosíntesis anterior existente en el fémur, debiéndose efectuar ambas operaciones a la vez. (Lo propio consta visible a folios 85 y 86 del expediente principal). Ya en el INS, en fecha 17 de marzo del 2012 y como parte del servicio brindado al actor, se le trasladó al Hospital La Católica en donde le fue practicada aquella intervención quirúrgica por parte del mismo doctor Max Rojas Carranza. Este además de no ser un hecho controvertido consta a folios 39 y 40 del legajo de prueba del INS. Dos días después, el 19 de marzo del 2012 el actor había sido nuevamente trasladado al INS, donde se reportó por su personal médico que por su obesidad no fue posible una mejor reducción, con riesgo de necrosis o pseudoartrosis de cadera. (Esto se extrae de la revisión de los folios 12 del expediente principal, en relación con el 84 y 109 del legajo de la medida cautelar y el testimonio en la audiencia complementaria por parte del doctor Javier Francisco Soto Fallas, quien explicó en juicio el procedimiento quirúrgico efectuado). Luego, para el día 21 de marzo del 2012 al actor se le habría dado traslado por parte de las autoridades médicas del INS a su casa de habitación. (Hecho no controvertido vistas las manifestaciones de la representación del INS en su escrito de contestación a la demanda). Al día 27 de marzo del 2012, ya se había agotado el monto de cobertura de la póliza del seguro obligatorio de vehículos automotores al tenor de la cual se le daba tratamiento al señor Gilberto Badilla Castro en el INS conforme obra prueba a folio 15 del legajo de medida cautelar y luego habría de explicar la conducta adoptada por parte de esa empresa estatal. Previo a ello, el día 09 de abril del 2012, el actor se había trasladado al INS, en donde por no encontrarse presente el doctor Max Rojas Carranza fue atendido por el doctor Javier Castro Figuls, quien señaló que presentaba la cadera con tres clavos con algo de “varo”, es decir, “curvatura”, y diagnosticó que en la cirugía practicada existía un daño en la cadera, procedió a removerle el “avión” que es el dispositivo empleado para impedir la rotación de la cadera que se le había colocado de forma posterior a la cirugía, y le señaló una cita para el 23 de abril siguiente, y finalmente, nuevamente fue enviado a su casa. (Este es un hecho que se tiene como robado a partir de no haber resultado controvertido vistas las manifestaciones de la representación del INS en el escrito de contestación a la demanda, pues esbozado en el escrito de demanda no fue rechazado en ese tanto). Al actor se le había programado una cita que habría de entenderse era de control, no obstante lo cual previo a ello, el día 12 de abril del 2012 se hizo presente en el INS nuevamente, en donde el doctor Max Rojas Carranza -quien le había tratado de forma anterior- se limitó a revisar la póliza del seguro con que se le dio atención, procedió a extender una epicrisis y procedió a darle traslado al actor a la Caja Costarricense del Seguro Social con causa en que el monto de cobertura de esa póliza se había agotado, -lo que dijimos había ocurrido el 27 de marzo del 2012, haciéndose indicación en la referencia que lo era al servicio de ortopedia y con carácter de urgencia . (Este hecho constituyó uno sobre los que no medió controversia al no ser rechazado por la representación del INS en su escrito de contestación de la demanda, que además se soporta visto el folio 189 del expediente clínico del INS, en que obra el reporte de notas médicas correspondientes). Ese era el estado de las cosas el día 17 de abril del 2012, mismo día en que habiéndose indicado al actor que ya no habría de ser atendido en el INS con causa en lo dicho, fue recibido en el Hospital San Juan de Dios conforme la referencia médica indicada, donde fue valorado por el doctor Daniel Martínez Castrido, quien indicó que había existido una falla en uno de los procedimientos realizados, específicamente la osteosíntesis, presentando tornillos migrados, cabella y cuello desplazados, y que ello correspondía a una complicación de la cirugía realizada por el médico del INS, por lo que estimándose que esa circunstancia excluía la responsabilidad de atención en la Caja Costarricense del Seguro Social, se le debía dar al paciente contrareferencia al INS. Así, fue egresado del Hospital San Juan de Dios ese mismo día, 17 de abril del 2012, consistiendo la falla referida en el procedimiento llevado a cabo en el INS, en que el hueso y/o sus fragmentos pese a la osteosíntesis practicada, no se encontraban alineados de manera propicia para la consolidación de la fractura. (Hecho no controvertido, vistas las manifestaciones de la representación de la CCSS en su escrito de contestación a la demanda, en asocio con el folio 20 del legajo de la medida cautelar y el testimonio en juicio del doctor Javier Francisco soto fallas, quien explicó con propiedad en juicio lo propio, en relación con el estado del paciente en ese momento y lo que se había registrado respecto a la falla en el procedimiento relacionado). De este modo, del Hospital San Juan de Dios se emitió el mismo día 17 de abril del 2012 contrareferencia para que fuese atendido en el INS. Sobre el particular, explicó en juicio con seguridad y propiedad en juicio el doctor Javier Francisco Soto Fallas, que para haberse obrado de la forma en que así lo fue conforme indicamos, habrían mediado razones médicas en lo que resulta más relevante. Siendo irrelevante para la resolución del presente asunto si medió o no una mal praxis médica de parte del personal médico del INS, particularmente del médico que intervino quirúrgicamente al actor, señor Max Rojas Carranza, informó el testigo Javier Soto Fallas, que pese haberse practicado por el INS un procedimiento al actor conocido como osteosíntesis, mediante el que se pretende reubicar el hueso fracturado en posición tal que se logre su consolidación mediante la colocación entre otros elementos, de tornillos o en su caso placas, lo cierto del caso es que al recibirse al paciente se observó que el hueso se encontraba desplazado y en ese entendido, mal implantados los tornillos que habrían de procurar lo contrario, por lo que en dos niveles, lo que correspondía desde el punto de vista médico primero, era que tratándose de eventuales complicaciones presentadas en el procedimiento, fuese el mismo médico que realizó la intervención quien observara nuevamente al actor, determinando qué complicaciones se presentaron en el caso concreto, así como las correcciones necesarias que debían aplicarse para paliar el problema de salud en el paciente. Por otro lado un tema deontológico, sino ético, que imponía al médico tratante en el INS tornar a la evaluación y corrección de la situación del paciente, si es que de su obrar no se pudieron paliar los problemas que padecía el señor Badilla -la fractura- esto asociado a los deberes que imperan en el ejercicio de la profesión médica según así lo entiende este Tribunal. Siendo esa la situación, fue la señora Mayra Torres Tapia quien acudió al INS a implorar con insistencia -según así lo aseguró con claridad en su deposición como testigo en juicio sin que medie razón alguna para dudar de la veracidad de su dicho- para que se le diera atención al señor Gilberto Badilla Castro visto que no la recibiría en el Hospital San Juan de Dios conforme la contrareferencia dicha, solicitud que fue rechazada con exclusiva causa en que se había agotado la cobertura de la póliza, remitiéndole nuevamente a la CCSS, con referencia y epicrisis, pero sin que se valorara de nuevo al paciente. (Este corresponde con un hecho no controvertido en parte, vistas las manifestaciones de la representación del INS en su escrito de contestación de la demanda quien no rechaza esa circunstancia, en relación con la declaración de la señora Mayra Torres Tapia en la audiencia complementaria de juicio). Dado lo anterior, el día 20 de abril del 2012 el señor Gilberto Badilla Castro se presentó al Hospital San Juan de Dios, en donde sin ser valorado de nuevo y por las misma razones por las que había sido referenciado al INS, se insistió por el personal médico de la CCSS en que debía ser atendido en el INS, no obstante se le dio cita de control para el día 26 de abril del 2012 -sin que quepa menor duda respecto de que la posición seguía siendo que el INS debía ser quien tratara al señor Badilla. (Hecho no controvertido, vistas las manifestaciones de la representación de la CCSS en su escrito de contestación a la demanda). El doctor Javier Francisco Soto fallas, fue claro en que la cita referida habría de serlo para decidir cómo obrar dependiendo del trato que se le diera al actor en el INS, y si se le atendía o no, y cómo. Con todo y ello, el día en que se programó su cita de control, a saber el 26 de abril del 2012, al actor se le recibió en el Hospital San Juan de Dios, en donde ese mismo día se consignó -otra vez- por nota del médico tratante Javier Francisco Soto Fallas, en la que consignó lo siguiente: “Paciente referido del INS por agotamiento de póliza. Sin embargo, hoy se presenta con historia de fractura de fémur izquierdo a nivel de la cadera con trazo transcervical, se realizó cirugía en el INS el 17/03/2012 con falla en la osteosíntesis, se presenta con tornillos migrados y cabeza y cuello desplazados. En este momento no se considera emergencia operarlo y desde el punto de vista médico legal es una complicación de la cirugía realizada por el médico del INS, el cual debe asumirla clínicamente con limitación a la flexión de la cadera por el desplazamiento de la misma “, sea, que aplicado al paciente un procedimiento quirúrgico mediante el que colocándosele dispositivos externos como, tornillos, placas, clavos etcétera, para alinear y/o unir el hueso o sus fragmentos a fin de promover la consolidación de la fractura, mediante la formación de puentes óseos y vasos sanguíneos de neoformación o nuevos que en ambos casos permitan el traspaso de los insumos que utiliza el hueso para consolidar, ello no se había logrado. El actor fue trasladado a su casa, no estimándose una emergencia el efectuar una operación aún y en ese estado , estimándose además y en lo principal que la condición que presentaba se encontraba asociada o era producto del procedimiento de osteosíntesis que le fue aplicado por el INS sin resultado positivo. (Folio 116 del expediente clínico del Hospital San Juan de Dios, en su tomo I, en relación con el folio 34 del mismo expediente en su tomo II, las manifestaciones de la representación de la CCSS en su escrito de contestación a la demanda y el testimonio en juicio de parte del doctor Javier Francisco Soto Fallas). La falencia en el procedimiento ya había sido detectada por el personal médico del INS como se dijo atrás, desde el mismo día 17 de abril del 2012, momento en que se mencionó una complicación asociada a la obesidad del paciente. En tanto, ni en el Hospital San Juan de Dios ni en el INS se encontró siendo tratado el actor en dirección a corregir su fractura en la cadera. Finalmente, el actor acudió a esta Jurisdicción en acción cautelar ante causam, fruto de la cual en fecha 30 de mayo del 2012, fue dictado dentro de la presente causa el auto identificado con el número 266-2012, al tenor del cual se ordenó exclusivamente a la CCSS “... atender médicamente al señor Gilberto Enrique Badilla Castro de forma íntegra respecto de cualquier afectación a su salud que se encuentre padeciendo, ya en virtud de las consecuencias del accidente de tránsito mismo que sufrió, ya de las operaciones quirúrgicas y/o tratamientos que le hayan sido o no practicados por terceros sin que medie distinción alguna”. (Ver los folios del 88 al 96 del legajo de medida cautelar). Se haya dado cita al actor o no por parte de ese centro médico con anterioridad para una fecha previa o posterior a la adopción de la medida cautelar, es lo correcto afirmar que no lo fue para efectuar procedimiento alguno que como se verá, era necesario para corregir la fractura que presentaba en la cadera, cuando antes bien y escuchadas las declaraciones en juicio del doctor Soto Fallas, lo era para decidir qué hacer dependiendo de lo que realizase el INS por su cuenta, esto, pese a que rechazada la atención del actor en el INS, también había sido rechazado el actor en el Hospital San Juan de Dios en dos ocasiones con conocimiento de esa circunstancia, mientras la fractura que presentaba no consolidaba con causa en el resultado del procedimiento realizado en el INS, o en su caso con causa en complicaciones propias de las circunstancias físicas del actor -lo que insistimos, resulta irrelevante, en la medida en que el actor no se encontraba siendo atendido de todas maneras para corregir directamente su mal -. De este modo, fue con causa en lo ordenado en la medida cautelar que el día 31 de mayo que fue recibido el actor nuevamente en el Hospital San Juan de Dios (hecho no controvertido en parte, en asocio con las declaraciones de la señora Mayra Torres Tapia) momento a partir del cual se le practicaron los exámenes de rigor de corte preparatorio, y se determinó necesario para paliar su condición -la fractura- la realización de una intervención quirúrgica, misma que le fue realizada con éxito el 25 de junio del 2012. Nada permite afirmar que ello no fuese posible de determinar semanas atrás. En esa operación se le realizó al señor Badilla un reemplazo total de cadera, no sin antes hacer retiro de tres tornillos canulados colocados por el INS en su oportunidad según así se infiere con claridad, y previo a la intervención se había verificado que el actor presentaba muerte o desaparición de material óseo. (Folios del 02 al 24 del el testimonio en juicio del doctor Javier Francisco Soto Fallas, el folio 84 del legajo de la medida cautelar y los folios 21 y 22 del principal) . El doctor Javier Francisco Soto Fallas explicó en juicio que el procedimiento normal o usual para una quebradura de cadera, lo es internar al paciente e intervenirlo quirúrgicamente, para adoptar las acciones necesarias, ya para que se consolide la fractura adecuadamente, ya para reemplazar la cadera. Por otra parte, practicad o al señor Gilberto Badilla Castro en el Hospital La Católica a requerimiento del INS, se realizó con falla que si no retrasaba, impedía la consolidación de la fractura de cadera que presentaba. (El testimonio en Juicio del doctor Javier Francisco Soto Fallas). Debe recalcarse que asegurado el actor o no por el INS, para el momento en que sufrió el accidente de tránsito y fue atendido en ambos nosocomios, se encontraba asegurado por su patrono como asalariado ante la Caja Costarricense del Seguro Social, laboraba como oficial de seguridad privada y se encontraba en unión libre con quien se identificó como Mayra Torres Tapia, ésta última, quien se encargó de dar atención al actor durante su convalecencia, en lo que lo fue en su hogar. (Hecho no controvertido, en relación con las declaraciones tanto del actor en su escrito de demanda, como en juicio, por parte de la señora Mayra Torres Tapia, y el folio 11 del legajo de la medida cautelar, 79 del principal). También se tuvo por acreditado que del día 17 de abril y el 31 de mayo del 2012, ni en la CCSS ni en el INS, su personal se consideró responsable de dar tratamiento directo y principal al actor dirigido a corregir a su estado -la fractura-. (Hecho no controvertido) 5.2.- Se concluye de lo anterior que la CCSS a partir del servicio prestado al actor desde el Hospital San Juan de Dios a través de sus funcionarios, incurrió en una conducta anormal en materia de prestación de servicios médicos, que constituye una conducta desajustada con el ordenamiento jurídico y causa de imputación de responsabilidad patrimonial, en nexo causal exclusivamente en relación con los daños de corte moral subjetivo que reclama el actor, pero de forma parcial, tal cual se adelantó líneas atrás y a partir del momento en que negó a uno de sus asegurados la atención médica que finalmente se sabe, requería, bajo el argumento de que ello correspondía al INS. No puede dejarse de indicar que ciertas o no las razones que desde la óptica de los funcionarios del Hospital San Juan de Dios, les condujo a referenciar al paciente al INS, lo cierto es que rechazada su atención en ese Instituto, se imponía atenderle sin dilación alguna, o en su caso, indagar con el INS sus razones para proceder de inmediato a definir qué hacer con el actor. Ninguna relevancia lleva a los efectos de la CCSS, analizar los alcances del seguro obligatorio de vehículos automotores, cuando de todas formas el actor era asegurado directo como asalariado en el régimen administrado por esta Administración pública accionada. Así, debieron tomar nota las autoridades médicas del Hospital San Juan de Dios, que con independencia de que el paciente presentase un problema asociado a una falla en el procedimiento practicado por el INS, así como que en su criterio, ya por razones médicas, ya por razones de responsabilidad civil correspondía al INS corregir el problema, lo cierto es que era una liberalidad del actor decidir si deseaba ser tratado por la CCSS o no. Con todo y que se le haya tomado parecer al respecto, véase que al 17 de abril del 2012 al menos era conocido -o al menos debió serlo por parte del personal médico del Hospital San Juan de Dios- que al actor se le había referido por el INS, con causa en que su póliza se había agotado, lo que algo pudo adelantarse sobre la suerte que correría el señor Badilla al presentarse ante esa empresa aseguradora. De este modo, previo a contrareferenciar al actor al INS para que fuese atendido en aplicación de su póliza y/o en su caso, por corresponder con un deber médico impuesto por razones médicas y/o por principios deontológicos, lo cierto es que un eventual rechazo del paciente era una posibilidad totalmente esperable o al menos posible -como en efecto lo fue-. Nada supone que no fuese deber de la CCSS atender el mal que padecía el paciente de forma eficiente y directa sin perjuicio de lo realizado por el personal médico del INS, siendo el actor asegurado directo del régimen administrado por la CCSS y al menos, si se estimaba que su atención debía de darse por el INS, habiéndose recibido el actor luego de ser rechazada su atención por el INS -conociéndose esa circunstancia- lo menos que se podía esperar era que previo a contra referenciar al paciente, se verificase con el INS si se le iba a atender o no de previo, en lugar del dejar al paciente a su suerte, como así se obró de forma ilegítima. El acceso al servicio de salud por una asegurado como el actor no puede ser condicionado o dejado a un tercero sin tener certeza de que será atendido. En el caso del actor se suma a lo anterior, que conforme las declaraciones en juicio del doctor Javier Francisco Soto Fallas el procedimiento normal para un caso de fractura en la cadera, es la intervención quirúrgica, para con ocasión de ella, corregir la posición del hueso -para lo que se puede hacer uso del implante de tornillos o placas- con el propósito de colocar la estructura ósea en posición que procure una adecuada consolidación de la fractura. Además, conteste que lo fue su testimonio con el rendido por la señora Mayra Torres Tapia, dos días después de realizada esta intervención, es esperable que el paciente ya pueda incluso dar pasos. Contrario a ello, de forma improcedente, le fue impuesto al actor visto el conflicto entre ambas instituciones sobre la responsabilidad de realizar este procedimiento, de todas formas necesario en el actor conforme lo actuado por la CCSS a partir del 31 de mayo del 2012, aguardar, incluso indefinidamente mientras se mantenía la disputa, hasta que no fue sino por la intervención precautoria por orden judicial dictada en contra de la CCSS, que se le dio la atención debida al actor. De lo anterior se tiene que efectivamente el actor sufrió desamparo en términos de la prestación de servicios de salud que debían ser oportunamente brindados, y esta circunstancia se mantuvo al menos del 17 de abril al 31 de mayo del 2012, conforme así lo reprochó el actor y según la causa de pedir expresada en su demanda, consecuencia de lo cual, se tiene que medió una conducta administrativa por parte del personal médico de la CCSS adoptada en desajuste con el ordenamiento jurídico, que guarda correspondencia con una conducta anormal en material prestacional, de la que como se verá, emergió un daño que debe ser resarcido en el actor al no encontrarse obligado a soportarlo y no mediar tampoco causa alguna que rompa ese nexo causal que debe mediar conforme la doctrina que informa lo dispuesto en el artículo 41 constitucional y 190 de la Ley General de la Administración Pública.- 5.3.- De forma sistemática analizada la prueba que obra al respecto, se tiene principalmente de las declaraciones de la señora Mayra Torres Tapia en la audiencia complementaria de juicio, en asocio con las reglas de la del 2012, lo era aliviarse de intensos dolores que sufría, así como librarse de su condición incapacitante que le impedía movilizarse por sí mismo , agravada por su obesidad y generada con causa en la existencia de una fractura en su cadera producto de un accidente de tránsito. Durante ese período de tiempo las dos instituciones demandadas, en principio llamadas a solucionar en lo correspondiente su situación, le negaron su atención, por razones diversas. Punto a parte las consideraciones que se harán respecto del INS, es claro que quien demanda no sólo era consciente de su derecho de ser atendido por la CCSS al tenor de ser asegurado directo como asalariado, sino de la injusticia que representaba la negación del servicio. Por otra parte, la señora Mayra Torres Tapia fue clara y creíbles sus declaraciones, en lo que se dirigieron a describir el estado físico y anímico del actor durante ese período de tiempo, mismo dentro del que para su atención dadas entre otras cosas, sus condiciones económicas, impedían proveerse de condiciones para su atención, o al menos para que su espera resultare confortable en lo posible. De hecho , describió cómo el actor debió permanecer por horas y durante días sin que nadie le asistiera en su hogar desde tempranas horas de la mañana, y hasta la noche, así como abundante en describir las precarias situaciones económicas por las que pasaron. También fue enfática en informar a este Tribunal, de cómo le constó que el actor experimentó grandes dolores, así como sentimientos que no podría esta Cámara dejar de describir por su cuenta, como de impotencia, angustia, desazón, frustración, enojo, tristeza, desesperación, alteraciones negativas en su carácter y capacidad de interactuar con la persona que se encontraba dándole cuido en lo que podía -su compañera en unión de hecho, señora Mayra Torres Tapia- incluso deseos de no vivir, todo con causa en que ni en la CCSS ni en el INS su personal se consideraba responsable de darle tratamiento directo dirigido a dar corrección del estado en que se encontraba, al tiempo que más básicas, dado que entre otras cosas, se encontraba impedido para valerse por sí mismo. Las más simples reglas de la lógica asociadas a la experiencia, así como las declaraciones del doctor Soto Fallas, en las que fue conteste en que una situación como la del actor produce dolor frente al que claro está, cada quien tiene mayor capacidad de tolerancia, dan cuenta de que si el actor debió valerse por sí solo durante ese período de tiempo tal y como lo hizo ver la señora Torres Tapia cuando no podía ver por él mientras trabajaba de siete de la mañana a las ocho horas de la noche, sin duda para atender las más simples de sus necesidades debió experimentar gran dolor -a lo que se suma que el insumo otrora colocado para impedir la movilidad de su cadera, le había sido removido-. Los sentimientos descritos, asociados a que era consciente de que su derecho a la salud se encontraba siendo lesionado , sin duda en cualquier persona habrían ocasionado un fuerte sentimiento de frustración y ansiedad. Con todo, este Tribunal estima que la responsabilidad que cabe no habrá de ser solidaria, por cuanto el criterio de imputación es muy diverso al aplicable al caso del INS como se verá, además de que estimamos, que la suma reclamada no resulta acorde con la intensidad con que el actor experimentó los efectos dañosos que se describen. La naturaleza jurídica de esta entidad y del servicio que presta a través de los hospitales que administra consideramos, impone un mayor reproche de responsabilidad frente al que puede ser atribuido al INS, que presta servicios de corte privado. Así, estimamos razonable y adecuado al mérito de las circunstancias que atravesó el actor, otorgar la suma de quince millones de colones a título de daño moral subjetivo , que deberá ser pagada por la CCSS a favor del señor Badilla Castro una vez firme el presente fallo, como en efecto sí se dispone.- 6.- Sobre la procedencia parcial de la demanda en contra del Instituto Nacional de Seguros. En lo que respecta al Instituto Nacional de Seguros, esta Cámara es del criterio que el haber negado atención al actor a partir de que su póliza de seguro se agotó en cuanto al monto de su cobertura, si bien y en principio se ajustó a lo que dicta la Ley de Tránsito por las vías públicas Terrestres, no puede estimarse una conducta ajustada a derecho, si se aplica el ordenamiento jurídico en su integridad al caso concreto, pero en materia de la prestación de servicios médicos a partir de la operación de un centro hospitalario. Este Tribunal es del criterio que aquí debe hacerse una separación entre lo que constituye una prestación de servicios al tenor del contenido y alcances de un contrato de seguros y lo que corresponde con las obligaciones que impone el ordenamiento jurídico en materia diversa a aquella, cual es la prestación de servicios como los brindados al actor una vez que se le aceptó como paciente en el Hospital administrado por el INS. Sobre este particular tópico, la regulación existente es de aplicación directa al INS en la medida que atienda a un paciente en su centro hospitalario, en lo que comprende el derecho de la constitución e internacional, que establecen como derecho fundamental y humano, el derecho y acceso a servicios de salud, que en todo momento deben ser integrales y deben poner en la cúspide de cualquiera que sea el interés institucional, el bienestar, también integral del sujeto tratado . Debemos partir de que como hecho probado se tuvo que el criterio de los médicos de la CCSS al recibir al actor después de que le fue practicada una cirugía en el INS, lo fue que presentaba una falla derivada del procedimiento que le fue practicado, que impedía la consolidación de la fractura en su cadera, de modo que fue su parecer por razones incluso médicas, que debía ser atendido por el mismo médico que le practicó tal procedimiento fallido. Lo medular es determinar si el actuar del INS en aplicación de lo que entiende son los alcances del seguro obligatorio de vehículos automotores, tiene la potencia de excluir su responsabilidad. La respuesta es negativa en criterio de esta cámara. Debemos insistir en que medie un contrato de seguros o no, de ser recibido un paciente por el INS y dársele tratamiento médico por su cuenta, se encuentra al tiempo regido por la normativa que impera en materia de la prestación de los servicios médicos, la operación de hospitales, los deberes y derechos de las personas usuarias de estos servicios y en lo que corresponde, tanto del Reglamento General Sistema Nacional Salud y el Código de Moral Médica que rige el ejercicio profesional de los funcionarios que trataron al actor en forma directa y/o, desde su posición como autoridades médicas hospitalarias. Empezaremos diciendo que luego de la cirugía practicada al actor, la remisión que se hizo de éste a la CCSS con causa en que el agotamiento de su póliza de habría dado, no es por sí sola, circunstancia de que se deba reprochar responsabilidad en la empresa. Cosa distinta ocurre luego de que se le niega atención al actor y la forma en que se obró al respecto, a partir de que el mismo es contrareferenciado por parte del Hospital San Juan de Dios. Primeramente, no habiendo sido ello negado por la representación del INS, a través de la señora Mayra Torres Tapia se imploró al INS por atención al actor con ocasión de que en la CCSS se le negaba el servicio y se encontraba partir exclusivamente del agotamiento de su póliza no es admisible, siendo el deber de su personal médico lo era haber indagado sobre las razones por las que en el Hospital San Juan de Dios se le referenciaba de nuevo. Esto fue omitido en su totalidad frente a las gestiones que efectuó en nombre del actor encontrándose debidamente autorizada para ello, la señora Mayra Torres Tapia. El actor presentaba una falla en el procedimiento médico efectuado por el INS en criterio de la CCSS, por lo que su personal tenía la responsabilidad de verificar si ello era así o no al menos, para luego decidir -se generen costos o no- cómo proceder con el paciente que ya era conocido, no se encontraba siendo aceptado por la CCSS. Contrario a ello, decidió simplemente no valorar el caso del actor y dejarlo a su suerte, a sabiendas de que en el Hospital San Juan de Dios no iba a ser atendido. Un mínimo de diligencia frente a la situación del actor, lo habría sido que previo a negarle atención se verificara con el personal del Hospital San Juan de Dios, que si le recibiría de vuelta o no. La contrareferencia al INS fue dada -con razón o no y entre otras- fundada en razones médicas, incluso deontológicas según así lo afirmó el médico del Hospital San Juan de Dios, doctor Javier Francisco Soto fallas, de modo que la negatoria de atención por parte del INS se habría esperado se fundase en razones de la misma índole, y no contractuales en función de los alcances de un contrato de seguros, pues en su actividad se fusionan la prestación de servicios de salud, con el de operador en el mercado de seguros, sin que ésta última actividad excluya la normativa que rige el funcionamiento de un hospital. En el marco de la prestación de servicios hospitalarios no está demás indicar, que el Decreto Ejecutivo N° 19276, del 09 de noviembre de 1989, Reglamento General del Sistema Nacional de Salud, dispone que el INS, junto con la CCSS y el resto de instituciones públicas y privadas que ahí se indican, forman parte de dicho sistema, debiendo actuar de forma articulada, esto es, sistemática y coordinada. En su artículo 9 se dice que: “Con el fin de garantizar la atención integral de la salud para toda la población, se reconoce el derecho de todos los ciudadanos a recibir servicios de salud, en las instalaciones del Ministerio de Salud, la Caja Costarricense de Seguro Social y el Instituto Nacional de Seguros, por consiguiente, no se podrá negar la prestación de los servicios integrales de salud a ninguna persona en particular, sin perjuicio de las posteriores comprobaciones y de los cobros correspondientes cuando procedan “. Integrante del sistema conforme el artículo 11 lo es el INS, que se encuentra concebido como una: “... institución que coadyuva a reducir en forma amplia y socialmente beneficiosa la incertidumbre económica que en forma individual y colectiva enfrentan los integrantes de la comunidad. Le corresponde ayudar a prevenir los infortunios laborales y de tránsito y otorgarles a los lesionados los servicios médicos hospitalarios y rehabilitativos en forma integral “. (El resaltado no es del original). Mientras que por su parte, el artículo 13 reza así: “Los establecimientos de salud estarán articulados entre sí en redes de oferta de servicios según niveles de atención, capaces de ofrecer cobertura universal con servicios en el primer nivel de atención y acceso escalonado a los niveles de mayor complejidad, según resulte apropiado a la necesidad del usuario”. Para este Tribunal es claro que al momento de darse la contrareferencia del Hospital San Juan de Dios al INS, tal y como luego ocurrió a partir del 31 de mayo del 2012, lo que el actor requería lo era una intervención quirúrgica para la corrección de su fractura en la cadera, aún y con el procedimiento realizado por el INS o como consecuencia del mismo, esto con causa en razones entre otras, de corte médico siendo lo ideal, que fuera tratado por el mismo galeno que efectuó el procedimiento que falló para la consolidación de la fractura de cadera al ser el profesional mejor ubicado para determinar qué complicaciones habrían surgido en el paciente. Finalmente, conforme el artículo 42 del mismo cuerpo normativo: “Son funciones básicas de los Hospitales, las siguientes: (...) 3) Coordinar actividades con los centros de mayor y menor complejidad en la red de servicios de salud y con los comités que representan a las comunidades “. Así, queda determinado que media un deber de coordinación en todo caso impuesto en el INS, de no dejar a uno de sus pacientes a su suerte frente a una referencia a otro centro médico, máxime en las circunstancias del actor y además, con ocasión de encontrarse siendo contrareferido por razones médicas y de responsabilidad en ese sentido. Desde el punto de vista ético -sino deontológico- el Código de Moral Médica, Decreto Ejecutivo N° 35332 del 15 de mayo del 2009, impone al profesional en su artículo 22, que: “... no debe hacer abandono de sus responsabilidades hacia su paciente, aún de manera temporal, sin dejar a otro médico capacitado e informado que lo sustituya en la atención de aquel , salvo motivo de fuerza mayor plenamente demostrado”. Esto habla de la posibilidad de relevarse de la atención de una paciente, para trasladarlo a otro profesional. Lo que es aplicable al caso concreto, pues al actor se le refiere a un centro médico que le remite de vuelta por razones médicas sobre las que no se indagó, para luego rechazar su atención, se insiste , no por razones médicas, como sí contractuales de corte diverso a la ciencia que nos ocupa. En todo caso, artículo 34: “Independientemente de dónde se lleve a cabo el ejercicio de la profesión, se deben respetar los intereses y la integridad del paciente”. Artículo 36: “El médico, desde el momento en que ha sido llamado a dar sus cuidados a un enfermo y ha aceptado, está obligado a asegurarle, de inmediato, todos los cuidados médicos en su poder, personalmente, o con la ayuda de terceras personas calificadas”. Artículo 42: “El médico debe aportar toda información pertinente al paciente, al momento de transferirlo para fines de continuidad del tratamiento, al finalizar la relación médico - paciente o si el paciente lo solicita”. (El resaltado no es del original). Finalmente, artículo 63: “Las relaciones del médico con los demás profesionales y personal de apoyo del área de la salud , deben basarse en el respeto mutuo, en la libertad e independencia profesional o laboral de cada uno, buscando siempre intereses comunes en pro del bienestar del paciente”. (El resaltado no es del original). De este modo, se impone por el ordenamiento jurídico el no ser indiferente frente a una contrareferencia como la dada al actor por parte del Hospital San Juan de Dios, lleve razón o no el criterio de su personal médico. Al menos debió haberse atendido al actor para valorarlo y con ello determinar si era responsabilidad o no del INS corregir un tratamiento o procedimiento mal ejecutado en su integridad y del cual era responsable ante el paciente, caso en el que de resultar responsable el INS, agotada o no su póliza no hay duda que impera el deber de corregir el problema del paciente si él así lo requiere o reclama , sin costo alguno por temas de responsabilidad médica como lo advirtieron los médicos de la CCSS. Observa este Tribunal que con lo actuado además se inobservó la Ley sobre derechos y deberes de las personas usuarias de los servicios de salud públicos y privados, N° 8239, artículo 2, inciso e), que dispone como derecho de estos usuarios el recibir atención de forma eficiente y diligente. El artículo 50 de la Ley General de Salud refiere que: “Los profesionales o personas autorizadas para ejercer en ciencias de la salud responsables, en razón de su profesión, por la dirección técnica o científica de cualquier establecimiento de atención médica, farmacia y afines, serán responsables solidariamente con el propietario de dicho establecimiento, por las infracciones legales o reglamentarias que se cometieren en dicho establecimiento”, lo que refuerza en algún grado lo actuado en los términos ya dichos por parte de los profesionales en medicina que contrareferenciaron al actor al del Hospital San Juan de Dios al INS, y correlativamente habría impuesto al Instituto al menos valorar al actor para determinar su suerte. Otra cosa es que como se advirtió, la CCSS a sabiendas de la posición del INS, insistiera en su posición en perjuicio de los intereses del afectado. Debió tomarse en cuenta según las declaraciones del doctor Javier Francisco Soto Fallas, que resulta racionalmente aceptable que el profesional idóneo para determinar las condiciones de salud del actor y el tratamiento que se debe seguir, lo sea el médico tratante, en este caso, quien practicó el procedimiento por ser el que mejor conoce lo que hizo y establecer a partir de ahí, cuáles habrían de ser los servicios de salud a que tiene derecho el usuario del sistema con fundamento en una relación que debería existir entre el conocimiento científico con que cuenta el profesional y la historia clínica del paciente. Entendemos desde esta perspectiva, que una entidad integrante del Sistema Nacional de Salud, en este caso el INS, no puede negar un servicio médico bajo las circunstancias en que se encontraba el actor aduciendo exclusivamente que no existe ya cobertura de la póliza, o que lo propio no se encuentre incluido en su plan de beneficios, cuando al contrario, en casos como el presente es deber de la entidad contar con todos los elementos que desde el punto de vista médico sean necesarios para fundamentar adecuadamente la decisión de autorizar o no el servicio al paciente , cosa que no hizo. Sumamos a lo anterior que aún y en la materia que nos ocupa, responsable es quien tiene legalmente el deber de reparar un daño, aun si no lo causo de manera directa o material, lo que es plenamente aplicable a los casos de responsabilidad médica en la medida que supone entre otras aristas, la obligación que tienen los médicos de reparar y satisfacer las consecuencias de los actos, omisiones y errores voluntarios e involuntarios incluso, dentro de ciertos límites claro está, contenidos en el ejercicio de su profesión. En materia de seguros respecto del INS, tenemos además que el seguro se desdobla, pudiendo por un lado tender a reparar el daño causado y nada más, o en su caso a hacerse cargo del tratamiento del paciente o usuario, aquí sobreviene la aplicación de normativa diversa a la que rige el mercado de seguros y sus productos. En el caso de la actividad médica son responsables todos aquellos involucrados directa o indirectamente en la ocurrencia del daño, tales como el médico, la clínica u hospital, los auxiliares, las aseguradoras por lo que no podría ampararse un centro médico en que como organización empresarial no le son aplicables las mismas reglas deontológicas que rigen a sus profesionales . Dicho lo anterior, es el criterio de este Tribunal que si bien podría no haberse encontrado impuesto por el ordenamiento jurídico, que fuese el INS quien corrigiese las fallas del procedimiento que efectuó en el actor, si lo estaba que debía de descartar su responsabilidad al tenor de la información contenida en la contrareferencia dada al señor actor por los médicos del Hospital San Juan de Dios, lo que le imponía al menos haberle valorado. Con causa en su actuar y como lo fue en la realidad, la situación del actor en la medida que no recibía atención en ninguno de los dos nosocomios, se prolongó injustificadamente como barrera al acceso a los servicios de salud a los que tenía derecho de forma oportuna , frente a una condición que tiene la potencia de afectar la calidad de vida de cualquier persona por lo incapacitante que resultaba la lesión sufrida, además de dolorosa, con lo que coadyuvó el INS con su conducta al daño moral que experimentó el señor Badilla Castro, situación que permite imputarle la responsabilidad reclamada, más de forma autónoma como lo fue para el caso de la CCSS y en razón de causas diferentes tal y como lo hemos expuesto, no siendo de recibo que exclusivamente al amparo de la Ley de Tránsito y la cobertura del seguro del actor, se haya encontrado legitimado para haber actuado de la forma en que lo hizo. La conducta así desplegada constituye una anormal en materia de prestaciones del servicios de salud, que generó un daño de la misma especie moral subjetivo por el que le fue reprochada responsabilidad a la CCSS, más, dada la participación de los hechos por parte de esta empresa estatal, se estima que es menor el reproche o imputación que habrá de hacerse al INS, por lo que se estima que el daño moral subjetivo habría de ser indemnizado en una suma de cinco millones de colones y así se dispone lo propio, en función de estimarse ese monto adecuado. Nota aparte, no puede dejar pasar la oportunidad este Tribunal para referirse a un aspecto sobre la atención que fue dada al actor, que se estima debe ser revisada por las autoridades médicas del INS. Consideramos que al paciente se le debe informar de forma adecuada y con la precisión que resulte posible visto su estado y la proyección de las atenciones que habrá de recibir por parte del personal médico del INS, en qué momento se agotará su póliza y cuales serán las consecuencias de ello, a fin de que tenga la oportunidad de decidir de manera informada si será en otro centro de atención que preferirá ser atendido. No se observa que esto esté ocurriendo en la actualidad al menos a partir del caso en estudio, de modo que se insta al Instituto demandado a tomar nota de esta observación para ocasiones presentes y futuras.- 7.- Sobre la improcedencia de los extremos petitorios de corte indemnizatorio por la acusada falta de subsidio de incapacidad, y por gastos asociados a la compra de medicamentos. De forma que resulta de suyo confusa, la parte actora peticionó lo siguiente a título de reclamo por daños y/o perjuicios en contra de ambas entidades demandadas y de forma solidaria: “1. Al daño causado por el tiempo sin atención a mi salud de cuarenta y cinco días, en que me encontré completamente privado de la asistencia médica y la falta de subsidio y de incapacidad durante ese tiempo por un monto de seiscientos setenta y dos mil cuatrocientos treinta y tres colones con sesenta y cinco céntimos”. Del daño peticionado apenas se logra identificar el constituido por la falta de subsidio e incapacidad médica -habremos de entender- que habría sufrido durante el tiempo dentro del cual no habría sido atendido por parte de ninguna de las partes demandas, siendo que ambas rechazaban dar atención al paciente. Así las cosas, en lo que no se encuentra identificado el daño, ningún análisis habrá de efectuarse al respecto, no encontrándose este tribunal mandado a elucubrar cuando en su lugar corresponde a la parte ser clara en lo que peticiona. Por otro lado, en lo que corresponde con el subsidio e incapacidad de forma vagamente enunciadas, así como el reclamo para que sean pagados gastos médicos al tenor de facturas, mayoría de las cuales no identifican al comprador de diversos productos farmacéuticos, baste con indicar que la demanda se declara sin lugar, en función de que no se acreditó por quien demanda que habiendo requerido el suministro de medicamentos a la CCSS dentro del lapso de tiempo que transcurrió del 17 de abril al 31 de mayo, ambos del 2012, se le hayan negado, así como que se le hayan de la misma manera, negado incapacidades o la entrega del respectivo subsidio, todo en ausencia de elementos de convicción que permitan afirmar lo contrario. Por lo demás, aunque se habló de maltrato hacia el actor en el Hospital San Juan de Dios de parte de su personal, no se encuentra dentro de los pretendido que se encuentre siendo reclamado reconocimiento alguno por ese por demás, supuesto reproche, por lo que ningún análisis se hará al respecto.- VIII.- Corolario. El actor no acreditó más que en parte los presupuestos que conforme el ordenamiento jurídico hacen procedente los reproches de responsabilidad formulados en contra de las entidades demandadas en los términos enunciados en la presente sentencia. En lo que no lo fue se impone por tanto declarar sin lugar la demanda, esto es, en lo que refiere al pretendido daño identificado o asociado a la ausencia de subsidio e incapacidad, así como al pago por gastos -facturas- en que acusó haber incurrido con causa en la conducta desplegada por los accionados. En lo que resultó procedente, dado que ambas entidades demandadas afectaron ilegítimamente el derecho a la salud y de acceso a servicios médicos del actor, de forma autónoma se les condena, a la Caja Costarricense del Seguro Social, al pago de la suma de quince millones de colones y al Instituto Nacional de Seguros al pago de cinco millones de colones, en ambos casos a título del resarcimiento del daño moral causado, todo a partir de la firmeza de la presente sentencia.-“