Health insurance company must finance new high-tech knee joint

LSG Darmstadt: Unterschenkelamputierter can go better with it
Statutory health insurance companies have to pay lower limb amputees for the direct compensation of disability also particularly expensive prostheses. The condition is that the costly aid offers a "significant advantage in use compared to the cheaper alternative", the Hessian State Social Court (LSG) ruled in a ruling published on Tuesday, November 28, 2017 (ref .: L 1 KR 211/15). The Darmstadt judges thus addressed the reimbursement of a microprocessor-controlled so-called Genium knee joint to a leg amputee.

The 82-year-old had to be amputated in 2012 because of a sports accident, the left lower leg and knee joint. His health insurance company supplied him in July 2012 with a 28,000-euro, so-called C-Leg prosthetic leg system. A month later, when he discovered the Genium knee joint in rehab, he applied for this prosthesis from his health insurance.

New knee joint at the expense of health insurance. (Image: rocketclips / fotolia.com)

Just like the C-Leg, the nearly 46,000-euro Genium knee joint is also microprocessor-controlled. The health insurance company, however, had to pay for the prosthesis because of substantial advantages when walking and standing. Since the C-Leg could partially be used in the Genium knee joint, additional costs of around € 26,000 would be incurred.

But the health insurance company refused the reimbursement for the Genium knee joint. The C-Leg is sufficient. The coveted knee joint let expect no significant benefit advantages.

In its judgment of 9 November 2017, the LSG contradicted. The health insurance company must reimburse the costs for the Genium knee joint. The prosthesis replaced a part of the body and thus serve the immediate disability compensation. In such a case aids should be granted if they offer "significant advantages" in everyday life in each individual case.

This is the case here. The sports enthusiast plaintiff could easily overcome with the Genium knee joint obstacles, stand on sloping ground and better stair climbing and backward than with a C-Leg. With the Genium knee joint the plaintiff reaches the highest mobility grade four, with a C-Leg the degree of mobility lies with him with two to three. For the 82-year-old, who is about as fit as a 60-year-old, the Genium knee joint is the only way to almost completely compensate for his disability.

The Federal Social Court (BSG) has also repeatedly decided to reimburse prostheses. On September 16, 2004, the Kassel judges ruled that the health insurances had to finance insured persons for the direct disability compensation of a C-Leg because of the "essential advantages of use" (Ref .: B 3 KR 1/04 R, B 3 KR 6/04 R and B 3 KR 2/04 R). Concerned people could cope with everyday life much better in comparison with the use of mechanical prostheses. A claim for optimal care does not exist.

In addition to a normal prosthesis, leg amputees can also claim a freshwater bath prosthesis, according to the BSG on 25 June 2009 (ref .: B 3 KR 2/08 R and B 3 KR 19/08 R). This satisfies the need for mobility in the home or swimming pool. But a special saltwater prosthesis would not have to be paid by the health insurances because it does not satisfy a general basic need of everyday life (Az .: B 3 KR 10/08 R).

Also special sports prostheses, for example in order to better play badminton, should not be at the expense of the community of insured, the BSG ruled on March 21, 2013 (Ref .: B 3 KR 3/12 R, JurAgentur Report dated June 5, 2013). Because the promotion of recreational and club sports belong basically not to the tasks of the health insurance companies in the supply of aids. fle / mwo