Health insurance sterilization is not paid

Only rarely does the cost for sterilization take effect

04/07/2014

A sterilization of the man must take over the statutory health insurance only in absolutely exceptional cases. Damaged genetic information in the sperm, which could possibly cause a disability of later children, do not count according to a recent verdict of the Landessozialgericht (LSG) Niedersachsen-Bremen. „Only in case of sterilization required by illness“ and if there is a risk that the mother will suffer serious damage to health through pregnancy, there is a claim against the statutory health insurance, according to the LSG communication in Celle.

In the current procedure has a man born in 1969, „who undergo twice a liver and once a kidney transplant“and then had to take numerous immunosuppressants to avoid the rejection reactions, complained to a reimbursement of his sterilization. Because the drugs can lead to the genetic information change in the sperm and later children of the plaintiff with birth defects come to the world. The health insurance of the man had refused a reimbursement, after which he moved first before the Social Court and after local defeat in the first instance before the National Social Court.

Sterilization of the plaintiff does not lead to the elimination of a disease
The LSG now followed the judgment of the Social Court and dismissed the appeal of the plaintiff, as this is in a position, „to physically use other contraceptive methods.“ A sterilization at the expense of health insurance would also be considered only if this is required by a disease or - as shown in the statements of the Federal Social Court (BSG) on this issue - „immediately triggered by pregnancy a serious illness of the mother“ could. There were no indications for this in the current case. A sterilization of the plaintiff does not lead to the elimination or alleviation of a disease. The im § 24b SGB V laid down criteria for a reimbursement of costs by the statutory health insurance funds should continue to be interpreted narrowly in the context of the current discussion on preimplantation genetic diagnosis.

Rather part of life planning as a medical requirement
The Federal Social Court go beyond - contrary to the arguments of the plaintiff - in its decision of 28 September 2010 (B 1 KR 26/09 R, Sozr 4-2500, § 27 a no. 12) did not expect a change of values ​​which could justify a cost assumption of sterilization, the LSG Niedersachsen-Bremen continued. Ultimately, the sterilization of the man in the first place part of his life planning and is therefore not covered by the entitlement to benefits against the statutory health insurance, said the 4th Senate of the State Social Court of Lower Saxony-Bremen (Decision of 13 February 2014, ref .: L 4 KR 184/11). (Fp)