Patients are often losers in the cost dispute

Patient should pay for knee surgery by head physician out of pocket

30/04/2014

A 30-year-old carpenter from Bretzfeld in the Hohenlohe district underwent a complicated knee operation at the Orthopedic Clinic in Markgröningen (OKM), which was carried out by the chief physician. For the clinic demanded about 1350 euros from the man. However, this moved to court because he saw his health insurance in the duty. However, the Landessozialgericht decided in favor of the fund, the patient should stay at the expense. About the case reported the „Ludwigsburger Kreiszeitung“.

Litigation over costs for chief physician treatment
After the 30-year-old became incapacitated by a Stutz from the scaffolding, he decided after four years to contact the chief physician of the OKM. This suggested the man due to the severe injury, a complicated surgical procedure in which the injured knee should be stabilized with a donor tendon instead of a body's tendon. The carpenter agreed and let his knee operate successfully. For the intervention, the OKM demanded just under 4,700 euros, of which took over the health insurance of the man, the IKK Classic, just under 3,300 euros. He himself had to pay for the chief physician treatment about 1,350 euros. Then the 30-year-old moved to the Heilbronn Social Court, because he demanded from his health insurance company, the payment of the full amount. The court doubted the legality of the double billing, as the clinic offered the man no alternative, and condemned the health insurance to cover the entire costs, including the chief physician treatment.

Dispute over surgery costs is carried out on the back of the patient
The health insurance company was in revision, so that the case was re-negotiated before the Regional Social Court in Stuttgart. „The Social Court in Heilbronn has put the case on the wrong track“, the newspaper quotes the 11th Senate. It would be enough if the IKK Classic took over the operating costs as part of a case lump sum. Treatment by the chief physician does not provide for the law and must be borne by the patient.

The patient should therefore stay on the treatment costs. However, this is particularly questionable because the carpenter was not adequately informed by the chief physician. The man assumed that only the experienced doctor could carry out the complicated operation in the clinic. This is also confirmed by records of the chief medical officer, which are available to the newspaper. It says: „The very complex procedure is offered only by very few clinics and can also be performed only by very experienced surgeons. In my department, I myself carry out this operation.“ However, Olaf Sporys, the Regional Director of the OKM, told the newspaper explicitly that the operation can also be performed by senior physicians. „Then no costs would have been incurred.“ The patient had requested the chief physician treatment. The denied the lawyer of the carpenter. „He would have taken a different path if he had been shown that“, he told the newspaper.

Now the case could go into the next round, because the 30-year-old is considering, according to his lawyer, to sue the Klink. So far he has refrained from doing so, since the result of the operation is very satisfactory.

Patients often lose in dispute with the health insurance
Again and again patients make similar experiences when the health insurance funds refuse to pay the costs for certain therapeutic procedures. It is not decisive whether a treatment procedure is effective or necessary, but rather the assumption of costs depends on whether the therapy is approved by the Joint Federal Committee (GBA) „recommended“ applies. If this is the case, the fund will pay for the costs, otherwise the patient will remain sitting on very high amounts. For example, a man suffering from the Epstein-Barr virus had to pay 70,000 euros for immunotherapy because his health insurance company refused to pay for the treatment. The State Social Court of Baden-Württemberg confirmed the decision of the health insurance on the grounds that it is a private medical service (file reference: L 11 KR 2307/07).