AOK Bayern has to repay 91 million euros

Landessozialgericht commits the AOK Bayern to the repayment of 91 million euros

The state social court of North Rhine-Westphalia has decided in an express procedure that the AOK Bayern must repay 91 million to the health fund. The health insurance company had received too many compensatory amounts after the introduction of the fund for the year 2009 and should reimburse them at the request of the Federal Insurance Office (BVA).

AOK Bayern refuses to repay the millions
AOK Bayern filed a complaint with the Landessozialgericht Nordrhein-Westfalen against the repayment obligation imposed by the BVA and at the same time made an application to suspend the stipulated repayment obligation as long as the legal action was not completed. At the state social court not only the application for interim legal protection was rejected, but also the claim of the health insurance against the final settlement for the year 2009 in the express procedure rejected. The judges at the Landessozialgericht stated in their judgment that the demands of the AOK Bavaria to the suspension of the repayment „absurd and outlandish“ was and obliged the health insurance company to reimburse the over-received 91 million euros in twelve monthly installments.

Land Social Court condemns the AOK Bayern for repayment
The inflated allocations to the AOK Bayer are essentially due to the controversial so-called „convergence clause“ which was established at the introduction of the health fund on the initiative of the Bavarian state government, in order to compensate for possible disadvantages due to the financial compensation to other federal states. The clause states, among other things, that no federal state may be burdened by the introduction of the health fund with more than 100 million euros in addition. Originally, this was to prevent possible discrimination against Bavaria. However, in 2009 AOK Bayern received substantial convergence funds, „although, in fact, it is not being hit by the introduction of the Health Fund“, this is the verdict of the Landessozialgericht. The final calculations of the BVA for the year 2009 showed that the health fund provided Bavaria with 3.4 million euros more. The complaint of the AOK Bavaria against the now demanded reimbursement of 91 million euros was therefore incomprehensible to the judges, because „the repayment of too much of the convergence means corresponds exactly to the purpose of the § 272 SGB V, as this should only cushion the additional burdens that were feared when the Health Fund was introduced.“ In Bavaria, the convergence clause was not applicable, since no corresponding additional financial burden had occurred, the judges continue. In addition, however, the Landessozialgericht also made it clear that there are general constitutional reservations to the convergence regulation which still need to be clarified.

Convergence regulation in the health fund leads to disputes
Helmut Platzer, Chairman of the Board of AOK-Bavaria, starts with his criticism of the convergence clause and cites this as a reason for refusing to pay his health insurer. „In the meantime, the compromise has been eroded so far by administrative means that only in a few other countries do slight effects occur,“ Platzer explained his doubts about the legal basis of the convergence regulation. Since the funds were already used for the Bavarian patients and the Bavarian service providers and also the promised payout of 55 million euros for the year 2010 is still outstanding, his health insurance would not be willing to repay the required sum, stressed Platzer. The verdict of the Landessozialgericht in Essen, which is responsible in the first instance for all complaints to the health fund, leaves the AOK Bayern now, however, no choice. The health insurance company will have to repay the overpaid funds within one year. How the entire procedure to the action of the AOK Bavaria against the convergence regulation will turn out remains to be seen, but after the express application was dismissed so clearly, the chances of success of the Bavarian health insurance are according to statement of process observers extremely bad. (Fp)

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