Full three weeks decision time for health insurance companies

LSG Munich: Postal period is not counted on the deadline
(Jur). The statutory health insurances have a full three weeks to decide on the benefit claim of an insured person. It is sufficient if the fund sends the decision within this period, as the Bavarian State Social Court (LSG) in Munich in a resolution announced on Wednesday, 25 May 2016, decided (Ref .: L 5 KR 121/16 B ER). The mail period is not counted towards the deadline.

According to the law, the health insurance funds have to decide on a benefit application "swiftly, at the latest until the expiration of three weeks". If an opinion from the Medical Service of the Health Insurance Funds (MDK) is required, the health fund must inform the applicant and the period is extended to five weeks. There are longer deadlines for dental treatment. If the fund can not meet these deadlines, it must also inform the insured. "If no reasonable reason is given, the service will be considered as approved after the deadline has expired".

Picture: dessauer - fotolia

The BSG had recently ruled that thereafter a health insurance fund could grant a benefit "by silence": If the health insurance does not respond within the three-week period, the application is deemed "fictitiously approved" (Judgment and JurAgentur Report, 8 March 2016, Az. : B 1 KR 25/15 R). The only condition after this is that the requested benefit belongs to the scope of benefits of the statutory health insurance and the insured person was entitled to assume that his health insurance fund had consented. The fund would no longer be entitled to a further examination.

In the case now decided by the LSG Munich it concerns the supply of an insured person with a medicine, which is not actually approved for his illness. The health insurance had answered the application still within the three-week period refusing, the letter was received by the insured but only two days later.

Nevertheless, the health insurance has adhered to the deadline, judged the LSG Munich. The legislature had wanted to give the coffers a full three weeks for their decision. Therefore, that period is not 'shortened by postal transit times. Also the risk of a delayed postal delivery do not carry the health insurance, so the LSG in his urgent decision from the 25. April 2016. mwo / fle