Health insurance does not always pay: 15 new judgments that you should know

1. The health insurance company must reimburse the journey in the ambulance, even if treatment did not take place in the emergency room

The case: As a rule, the insurance company pays for the transport to the hospital if it is medically necessary. The emergency doctor or the doctor in the emergency room must confirm this need. But what if the rescue team takes the patient to the outpatient emergency service instead of the emergency room? It doesn’t matter, says the Detmold Social Court. The plaintiff, who is diabetic, noticed at home his blood sugar level was derailing. An emergency for which he correctly dialed 112. However, the ambulance did not take him to the emergency room, but to the nearby ambulatory emergency service. Only then did I go to the emergency room. From there, the patient was discharged that same night when his blood sugar normalized. The health insurance company then refused to pay for the ride in the ambulance. Wrongly so, so the judges in Detmold. (Social Court Detmold, judgment of 05.11.2019, Az.S 5KR 460/1)

2. Senior shared apartments do not have to take care of each other

The case: A group of seniors with and without dementia live together in a shared apartment. Some apply for medical treatment care, i.e. help with simple activities such as putting on and taking off compression stockings, administering medication and measuring blood sugar. However, the health insurance company rejected the application on the grounds that these activities could also be expected of laypeople. Other helpers in the shared apartment should also take on these tasks. The Bavarian State Social Court saw it differently: As long as such care services are not recorded in an agreement between the residents, it remains the duty of the health insurance company to pay for them. (Bavarian State Social Court, judgment of 08/20/2019, Az. L 5 KR 402/19, L 5 KR 403/19, L 5 KR 404/19)

3. Health insurance company has to take over GPS devices for patients with a tendency to run away

The case: The doctor of a young man with Down syndrome requests a wrist-fixable GPS transmitter for his patient. This tends to run away from the facility in which it is housed. However, the health insurance company refuses to cover the costs of the device. It demands that the patient be locked in and monitored completely. The state social court of Lower Saxony-Bremen, however, condemns the health insurance fund to assume the costs because a GPS transmitter enables the patient to participate in normal life, unlike locking him away or monitoring it completely. (Landessozialgericht Niedersachsen-Bremen, judgment of 17.09.2019, Az. L 16 KR 182/18)

4. Health insurance must also cover novel treatment in the USA

The case: A boy from Bremen suffers from a serious illness for which there was no cure until recently. When the parents heard of a clinical study in the USA, they applied to their health insurance company to allow their son to be treated by the responsible doctor. The health insurance company commissioned experts from the MDK and other medical professionals, who all came to the conclusion that there was no alternative to treatment. Nevertheless, the cash register declined. In an urgent procedure, the Bremen Social Court ruled that the health insurance fund had to bear the costs. In the end, the judges also condemned the health insurance fund to finally pay the costs, as all the doctors emphasized the necessity of the treatment. Neither the country nor the actual success of the therapy play a role. (Social Court Bremen, judgment of 23.10.2018 Az.S 8 KR 263/1)

5. Tooth complaints do not justify paying for professional teeth cleaning

The case: A patient with periodontal disease applied to his health insurance company for professional teeth cleaning. This refused and the patient went to court. But this also gave him a refusal. First, the man must – if at all – follow the applicable path, according to which additional costs must be clarified beforehand with the health insurance company and, secondly, they only have to assume the costs for services for which there are no services in the event of system failure or in cases of a life-threatening or regularly fatal illness Recommendation of the Federal Joint Committee. (Social Court Stuttgart, judgment of 30.05.2018, Az.S 28 KR 2889/17)

6. In exceptional cases, sick pay may also be given if you report sick again too late

The case: Actually, an insured person who receives sick pay must provide complete proof of his incapacity for work. But now the State Social Court of Hesse has set exceptions in two cases. Both are similar: shortly before the certificate of incapacity for work expired, both insured persons turned to their family doctor to get an appointment on the same day and both were put off until another day. The doctor then determined the incapacity for work, but the fund declined further sick pay payments. Wrongly so, according to the regional social court. A sick person does not have to secure a doctor’s appointment in advance, nor does he have to go to another doctor. “Doctors hopping” is expressly not desired, according to the court. (Landessozialgericht Hessen, judgment of December 22nd, 2020, Az: L 1 KR 125/20 and L 1 KR 179/20)

7. Sick pay must continue to be paid even when traveling abroad

The case: Going on vacation is not a reason for not receiving sick pay. That was decided by the Social Court in Karlsruhe. The prerequisite is that the trip has been clarified with the doctor and that you are on sick leave for the entire period. The existing regulations, according to which the sickness benefit is suspended when traveling abroad, are intended to ensure that the incapacity for work is fully proven. If this is guaranteed, a vacation can also be conducive to recovery and should therefore not be rejected across the board. (Social Court Karlsruhe, judgment of February 20, 2018, S 4 KR 2398/17)

8. Anyone who wants health insurance benefits needs an electronic health card

The case: Several insured persons fought against the electronic health data. They saw security gaps and feared for the security of their data. So they asked for a paper letter instead of the card. The Federal Social Court has given him a rebuff. The health card meets the requirements of the European Data Protection Regulation (GDPR). In addition, it serves as a protection against abuse of performance. (Federal Social Court, judgment of January 20, 2021, Az. B 1 KR 7/20 and B 1 KR 15/20)

9. A paraplegic person is entitled to a handbike

The case: An insured person who has been in a wheelchair for years applied to his health insurance company for a handbike, an electric pulling aid for his actual wheelchair for 8,500 euros. This would enable him to negotiate curbs and steep inclines and use the built-in crank to strengthen his shoulder muscles and thus prevent tension, the insured said. In addition, he could assemble the handbike himself without outside help. The health insurance company rejected the application and offered him an electric wheelchair for 5,000 euros. The insured did not want that, because he would need help to transfer to the power wheelchair. The Hessian State Social Court decided that so that the patient could participate in public life, the health insurance would also have to pay more expensive funds than basic care. The main reason for the decision was that the insured person could assemble and use the handbike alone. (Hessian State Social Court, judgment of October 13, 2021, AZ. L 1 KR 65/20)

10. In the case of permanent hair loss, the health insurance company has to pay for a real hair wig

The case: The plaintiff suffers from alopecia totalis, i.e. the complete loss of hair on her head, and is therefore entitled to a wig. She therefore wears a real hair wig, as it lasts much longer than a wig made from synthetic hair. The health insurance company only pays synthetic hair wigs and points out that these can hardly be distinguished from a real hair wig. The Dresden Social Court ruled that aesthetics did not play a role in the payment, the only thing that was important was that the real hair wig could be worn for twice as long as the synthetic hair wig. Therefore, from an economic point of view, the health insurance company must also take on these. (Dresden Social Court, court ruling of February 18, 2021, Az: S 18 KR 304/18)

11. Health insurance has to pay for treatment despite misdiagnosis

The case: A 66-year-old insured person suffers from an illness that can be treated with an off-label drug. This means that a drug that has been approved for another treatment is used outside of this approval. The health insurance companies generally reject such off-label use and are therefore right. In the present case, however, it turned out that the diagnosis was wrong, not the treatment. In fact, the insured suffered from the disease for which the drug was approved. The health insurance company still refused to pay because the drug was wrongly prescribed. The Hessian regional court, however, sentenced the cash register to pay. (Hessian State Social Court, decision of 09/10/2020, AZ. L 8 KR 687/18)

12. Skin tightening surgery is considered approved if the health insurance company does not make a decision in good time

The case: After gastric bypass surgery, the applicant quickly lost 40 kilograms, which resulted in sagging flaps of skin on her arms, breasts, abdomen and thighs. She therefore applied to her health insurance company for a skin tightening operation. Health insurance companies have five weeks to process such an application. The health insurance company also contacted the plaintiff within this period and put her off to an appointment with the medical service of the health insurance companies (MDK). However, this letter was not signed and there was no responsible clerk. This is exactly what the Heilbronn Social Court criticized and agreed with the applicant. (Social Court Heilbronn, judgment of November 22, 2019, Az. S 14 KR 3166/18)

13. Health insurance must also cover private surgery abroad

The case: In this case, too, a patient wanted the cost of a skin tightening to be reimbursed by the health insurance company and again she did not refuse it in due time. He then had an operation in Turkey. The health insurance company did not want to cover these costs precisely because the operation took place abroad. The Federal Social Court sees no way out for the health insurance company. You have to pay, regardless of whether the customer had the operation carried out at home or abroad. (Federal Social Court, judgment of 11.09.2018, Az. B 1 KR 1/18 R)

14. Health insurance does not have to pay for breast removal out of fear

The case: A woman from Bremen wanted to have a breast amputated because she repeatedly felt benign lumps. She suffers from “fear of cancer” and thus from considerable psychological stress. The State Social Court of Lower Saxony-Bremen declined, however: benign nodes only have to be checked regularly, but not removed. The removal of the breast is disproportionate to this. (Landessozialgericht Niedersachsen-Bremen, judgment of 04.09.2019, Az. L 16 KR 73/19)

15. Missing phalanx is not a major handicap

The case: The airline employee had lost the first phalanx of her index finger after a riding accident years ago and has since been wearing a finger prosthesis with a nail. When this was worn out, she applied for a new one from her health insurance company. However, this refused to pay after an expert opinion by the MDK: The prosthesis is not necessary, all finger functions are also given without it. A cup guard is sufficient against pain. The plaintiff argued that her hands were always the focus of her work, but still lost. (Social Court Mannheim, judgment of 04/04/2019, S 15 KR 3170/17) A necessary finger prosthesis that maintains or significantly improves the function of the hand, on the other hand, is accepted, just decided the Hessian State Social Court in another case. (Ref .: L 8 KR 477/20)


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