Health insurance companies have to pay Lucentis

AMD: Kassen have to pay for Lucentis

09/04/2014

Patients receiving the drug for the treatment of age-related macular degeneration „Lucentis“ In the future, the costs can be fully reimbursed by their health insurance. This has been decided by the Federal Social Court in a recent ruling.

Macular degeneration can lead to loss of central vision
Age-related macular degeneration (AMD) is a very common disease of the eye among the elderly, leading to vision loss in the area of ​​sharpest vision (macular). To treat the disease is often the drug „Lucentis“ the company Novartis used, which in a “Vial for single use” and must be injected by the doctor into the patient's eye.

Drug not yet „Uniform rating scale“ listed
For many concerned, however, so far an expensive affair: Because there injections into the eye so far not in the remuneration system of medical care, the „Uniform rating scale“, insured persons were able to settle the treatment until now only privately. Accordingly, the syringes had to be paid first, then the cashier could decide in which amount the costs will be reimbursed.

Widow complains of reimbursement of treatment of her deceased husband
But now the Federal Social Court has decided contrary to current practice in a recent judgment. In that case, a late-onset macular degeneration patient had requested reimbursement from his health insurance provider for three injections of Lucentis amounting to 1523.96 euros per injection. However, the fund approved only part of the cost, on the grounds that it was possible „to divide the disposable syringe into two or three patient-appropriate dosage forms“, so the message of the court. However, since the insured claimed to receive the drug compliant, only a private treatment was possible, resulting in costs totaling € 5769.78. The widow and sole heir of the man complained and won, because the social court decided after § 13, third sentence, sentence 1, case 2, that the fund must assume the full cost of the treatment.

Patients have a right to receive authorization
According to this, insured persons would not have to take their will against dividing the disposable syringe into two or three doses due to possible risks. In addition, the fund could not rely on the fact that the billing of the treatment had corresponded formally, but not materially the fee scale for doctors. The reason: The defendant cashier had not offered the insured to support him in a lawsuit against the attending physician and to waive the costs. (No)