When health insurance companies do not pay therapies
When health insurance companies do not pay effective therapies
12/12/2011
Often, therapy costs are not covered by the statutory health insurance, because the effectiveness of treatment as „not scientifically proven“ applies, although a recovery of the patient was started. The same happened to a patient who undertook an immunotherapy after an infection with the Epstein-Barr virus. According to a court ruling, the man remains on the treatment costs of over 70,000 euros because the treatment is not medically recognized (file reference: L 11 KR 2307/07).
Statutory health insurance companies can stay on top of the cost of treatment if treatment by the Federal Joint Committee (JCC) is not considered as „recommended“ applies. Like the working group „Medical law“ of the German Bar Association, the Landessozialgericht Baden-Wuerttemberg has rejected a corresponding claim of a patient, although insured persons of the statutory health insurance§ 27 SGB V) are entitled to treatment if this appears necessary to diagnose, cure or alleviate the illness of the insured person or to stop or slow down the progression. A medical therapy also explicitly includes the supply of medicines. But there is also a restriction in the legislation that states that health services are in line with the current state of medical science in terms of their effectiveness and quality. Therapies in the field of homeopathy, naturopathy and osteopathy are largely excluded, even if they provide the patient with relief of the symptoms or even the healing of the disease.
In their communication, the lawyers point to a ruling by the Landessozialgericht Baden-Württemberg. The judges decided that treatment must be in line with the current state of medicine in terms of quality and effectiveness. For newer treatments or diagnostic agents, this will only be the case if the GBA recognizes the benefits of treatment.
In the specific case, the plaintiff suffered from the Epstein-Barr virus and underwent an immune balance therapy to combat chronic fatigue. The corresponding preparations were prescribed to the plaintiff by a doctor. The cost of it in the true sense „Dietary supplements“ distributed funds totaled 73,000 euros. The court proved it was proven that the preparations are not approved by the GBA. In addition, it would be a dietary supplement whose costs are not taken over by the health insurance companies anyway. In addition, there was no risk to the patient's life, which is why a calamity-like illness did not exist. (Sb)
Picture: Berlin-pics