Health insurance performance approval can also happen by silence

Kassel (jur). A health insurance company can also grant benefits by silence. If the fund does not respond within three weeks, the application is deemed to be "fictitiously approved", ruled on Tuesday, March 8, 2016, the Federal Social Court (BSG) in Kassel (Az .: B 1 KR 25/15 R). The only condition after this is that the requested benefit belongs to the scope of benefits of the statutory health insurance and the insured person was entitled to assume that his health insurance fund had consented.
Specifically, the Knappschafts-Krankenkasse obliged it to pay an insured person 24 sessions of deep psychology-based psychotherapy. On the advice of his therapist, the current 31-year-old had made his request for benefits following a short-term therapy taken over by the health insurance fund. The miners had obtained an MDK report, but did not inform the applicant. Only after almost six weeks came the refusal.

Image: vege - fotolia

Meanwhile, the man had begun a therapy with 24 sessions but on his own account. From the health insurance company, he now demanded reimbursement of 2,200 euros.

According to the law, the health insurance funds have to decide on a benefit application "swiftly, at the latest until the expiration of three weeks". If an opinion from the Medical Service of the Health Insurance Funds (MDK) is required, the health fund must inform the applicant and the period is extended to five weeks. There are longer deadlines for dental treatment. If the fund can not meet these deadlines, it must also inform the insured. "If there is no notification of a sufficient reason, the service after the deadline is considered approved," it says literally in the Social Code.

Nevertheless, the miners said the deadlines should not lead to the insured get benefits to which they have no claim. Otherwise, the abuse would "open the door". Finally, the health insurance companies are committed to profitability.

The BSG did not allow this argument. The aim of the legislature was a timely supply. The miners did not answer their insured for more than three weeks. Therefore, the benefit claim is considered "fictitiously approved".

Other applies only to applications that are obviously outside the liability of health insurance. Here, however, the insured had to be allowed to start a permit because his therapist also supported the therapy. Therefore, the miners would have to pay the cost of self-procured therapy sessions, judged the BSG. (Mwo / fle)