After a fainting spell, a man with private health insurance allowed his family doctor to admit him to the S. clinic, where he had already been treated for an exhaustion syndrome. At that time the health insurance had reimbursed the costs – out of “goodwill”. This time, she refused the policyholder’s application for reimbursement.
His psychological problems – headaches, ringing in the ears, exhaustion – can also be treated on an outpatient basis. Nevertheless, the patient decided to stay in the clinic. For this he paid € 7,046 plus € 1,340 for optional services.
He then sued the insurance company to pay the costs and justified the claim: Due to the complex clinical picture, inpatient treatment was medically necessary. When assessing what is medically necessary, financial aspects should not play a role. The principle that outpatient treatment should be preferred for reasons of cost applies to statutory but not to private health insurance.
That contradicted that District Court Mannheim (Az. 9 O 383/19). Inpatient clinic treatment is only to be regarded as medically necessary if the desired treatment success cannot be achieved with outpatient therapy. That is not the case here, as the expert has confirmed. Therefore, the private health insurance does not have to reimburse the costs.
In private health insurance too, outpatient treatment has priority in principle. However, this does not mean that the policyholder always has to be referred to the cheapest treatment. When it comes to the question of “outpatient or inpatient”, it is not just about the costs of the therapy, but primarily about additional expenses for accommodation, meals and care. The insurance company only has to bear this if these points are unavoidable. OnlineUrteile.de
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