Health insurance companies have to decide quickly

BSG strengthens "fictitious approval" for requested services

The statutory health insurance funds must continue to decide quickly on benefit claims of the insured. The Federal Social Court (BSG) in Kassel has now strengthened the otherwise "fictitious approval" and made it patient-friendly (Ref .: B 1 KR 30/18 R and B 1 KR 13/17 R).

After a change in the law from 2013, the health insurance companies have three weeks to process a claim for benefit. If you get an opinion from the Medical Service of the health insurance companies (MDK), it is five weeks. In 2016, the Federal Social Court in Kassel had emphasized that in the event of a breach of these deadlines, the application was deemed to have been "fictitiously approved" (judgment and JurAgentur report dated 3 August 2013, ref. B 1 KR 25/15 R) and several more times thereafter affirmed (last judgment and JurAgentur report of 11 September 2018, ref .: B 1 KR 1/18 R). Other applies then only if the requested service is obvious and for the patient recognizable outside the catalog of benefits of the funds.

In the negotiation on the new cases, the BSG now called the legal deadlines "athletic", but they were binding on the health insurance funds as well as the courts.

Specifically, the BSG ruled that the extension of the MDK deadline only applies if the applicant is informed of the intended opinion within the original three-week period. This had missed the health insurance here. The applicant suffering from bowel cancer therefore has to pay for treatment with immune cells (so-called dendritic cells).

In another case, the patient - also for medical reasons and with medical support - had lost 60 kilograms. The doctors of the treating clinic then advocated a skin tightening on the chest, stomach and thighs, with a tightening of the thighs in the opinion of the doctors is only possible if previously further fat is sucked.

The health insurance company refused this only after more than five weeks. But she said, at least the liposuction, the so-called liposuction, is obviously outside the benefits of statutory health insurance.

This contradicted the BSG. Thereafter, this argument usually no longer applies when the health insurance fund has obtained an MDK opinion. This was the case here. The report shows that the cash register was also uncertain and needed clarification, the Kassel judges argued.

In addition, the patient had to rely on the assessment of her doctors, the BSG continues. It emphasized, however, that this no longer applies to purely cosmetic surgeries such as the breast. It is well known that the health insurance companies do not pay this. The specific case was, however, "at the border between physical complaints, mental suffering and cosmetics". mwo / fle