Judgment health insurance must take over costs for mother child cure

If a health insurance company takes too much time to decide on a claim for a mother-and-child cure, the application is considered "fictitiously approved". If the Medical Service of the health insurance funds (MDK) is commissioned to examine the reimbursement of costs, the health insurance company has only five weeks to decide on the application, the Landessozialgericht (LSG) of North Rhine-Westphalia emphasized in a recent decision of 27 March 2017 ( Ref .: L 1 KR 702/16). It does not matter for the assumption of costs whether the insured for the measure has already gone into advance, the Essen judges with reference to the legal provisions and the case law of the Federal Social Court (BSG) in Kassel.

According to the law, health insurance companies have to decide on a benefit application "swiftly, at the latest until the expiry of three weeks". If an MDK opinion is required, the Fund must inform the applicant and the deadline is extended to five weeks. If the fund can not meet these deadlines, it must also inform the insured.

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In the case now decided, a mother had applied for the reimbursement for a mother-child cure at her health insurance company on 22 June 2015. The fund informed the woman that she had forwarded the application to the MDK.

With the MDK expert's report, the health insurance company refused to pay for the measure on 3 August 2015, and thus only after more than five weeks. The woman has already received a mother and child cure in the past four years. A further cure is possible in this time only for urgent medical reasons, which are not present here, so the reasoning.

The LSG obliged the health insurance to cover the costs. Because the health insurance did not decide on the application within the prescribed five weeks. This application is deemed to be fictitiously approved.

Without success, the health insurance had argued that the approval fiction could only apply to applications in which insured persons have already gone into advance. This was not the case here with the mother.

However, the Essen judges referred to the case law of the BSG. From the judgment of the Supreme Social Justice of 8 March 2016 (Ref .: B 1 KR 25/15 R; JurAgentur message from the day of the judgment) make it clear that the approval fiction is also valid if the insured for the performance has not yet been in advance is. Otherwise, destitute pensioners who do not have this financial opportunity would be disadvantaged. fle / mwo / fle