Judgment health insurance may not give up dementia patient

LSG Stuttgart awards her medical rehabilitation

Health insurance companies should not just give up dementia patients. "Even in advanced dementia, the existence of rehabilitation capacity and a positive prognosis for inpatient rehabilitation measures is not excluded", emphasized the State Social Court (LSG) Baden-Württemberg in Stuttgart in a currently announced judgment of July 17, 2018 (Ref .: L 11 KR 1154/18). It awarded a 78-year-old woman reimbursement for a four-week rehab.

The woman has been suffering from Alzheimer's since 2013. The neurologists treating them advocated and applied for a inpatient rehabilitation program in 2016 in a therapy center specially designed for Alzheimer's patients. There is a mild to moderate dementia of the Alzheimer's type. With inpatient treatment, the course of the disease can probably be favorably influenced. As targets of the rehab the doctors called the physical and mental activation as well as "help to the partial self-help".

The medical service of the health insurance (MDK) turned on by the health insurance company had a different opinion. The woman is not capable of a rehabilitation measure and therefore there is no positive prognosis. The MDK did not respond to the specific clinical picture and the goals mentioned by the doctors.

Based on the MDK report, the health insurance company refused to take over the excess of the excess of 5,600 euros.

But the report was far too general and the rejection therefore illegal, judged the LSG Stuttgart. The statements of the MDK suggested "speculative", type and severity of the disease had not appreciated the MDK. The treatment goals cited by the physicians, which should be the main focus here, have not been tested by the MDK.

"The claim to rehabilitation requires a need for treatment, rehabilitation ability and a positive rehabilitation prognosis," said the Stuttgart judges. "All three prerequisites have existed." This results from the statements made in advance of the treating neurologists.

That these assessments were correct, have subsequently confirmed by the discharge report of the therapy center. Thereafter, the woman had become more communicative and familiar with other people, and her general mood had also improved. Also, her motor skills and endurance had improved so that she was able to go last three kilometers with a rollator. mwo / fle