Health insurance No full foreign costs

Health insurance companies do not have to take full advantage of treatments abroad

The Federal Social Court in Kassel has decided that German health insurances must carry treatments of their members abroad only in such height, as they would have also originated with a comparable treatment in this country (file reference B 1 KR 14/09 R). The case: A 1939 born man, who has his permanent residence in Germany and is insured by a health insurance, had operated in 1982 and 1992, once in a London clinic on the heart valves, whereby a so-called „bioprosthetic“ Aortic valve "ie a heart valve consisting of tissue from deceased organ donors, was transplanted.For the costs came in both cases, the compensation fund of the man in full, as the operations at the time in this country would not have been possible in 2005, the plaintiff had again and, as in the previous cases, filed a new application for the reimbursement of the costs - but unlike in the 23 or 13 years before, the health insurance company was now only willing to pay in proportion to the payment and only in „exceptional case“. The result: The Ersatzkasse took over only the sum, which would have become due in a corresponding hospital in this country (24.000 €), which meant for the plaintiff that he had to pay 12.000 euro of the total costs of the OP (36.000 €).

The court had to decide now and assessed - as mentioned above - the action of the health insurance as lawful and also found that there was no claim that could justify the reimbursement of the full costs for an exceptional case.

Thus, the costs for the first two operations would have been completely taken over for the sole reason that the transplantation of bioprosthetic heart valves in Germany was not possible at that time. However, since this situation has changed in the meantime, it would also have been reasonable for the plaintiff to go into treatment here. Also the objections of the man, that he trusted the doctors in the London clinic very much and he was treated there in his opinion better and less risky, as it would have been the case in Germany, the judges rejected - on the one hand it was not for the solidary community on the other hand, there would be no evidence for the assumed higher competence of the British doctors in the specialist literature. Therefore, the health insurance would not be obliged to pay the full amount for such treatment. (Sb, 21.02.2010)