Health insurance companies have to decide quickly

Health insurance companies have to decide quickly

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BSG strengthens “fictitious approval” for requested services

The statutory health insurance companies must continue to quickly decide on the claims of the insured. The Federal Social Court (BSG) in Kassel has now strengthened the otherwise “fictitious approval” and made it more patient-friendly (Az .: B 1 KR 30/18 R and B 1 KR 13/17 R).

After a change in law in 2013, health insurance companies have three weeks to process a benefit application. Get an opinion from the Medical Service of the Health Insurance Funds (MDK) for five weeks. In 2016, the Federal Social Court in Kassel emphasized that in the event of a violation of these deadlines, the application was considered “fictitiously approved” (judgment and JurAgentur report of August 3, 2013, file number: B 1 KR 25/15 R), and several times thereafter affirmed (most recently judgment and JurAgentur announcement of September 11, 2018, file number: B 1 KR 1/18 R). Otherwise, this only applies if the requested service is obvious and recognizable to the patient and is outside the health insurance catalog.

In the negotiations on the new cases, the BSG now described the statutory deadlines as “sporty”, but they were nevertheless binding for the health insurance companies and the courts.

Specifically, the BSG ruled that the extension of the deadline when the MDK is involved only applies if the applicant is informed about the intended report within the original three-week period. The health insurance company had failed to do this. The applicant suffering from colorectal cancer must therefore be paid for treatment with immune cells (so-called dendritic cells).

In another case, the patient lost 60 kilograms - also for medical reasons and with medical support. The doctors in the treating clinic then advocated skin tightening on the chest, abdomen and thighs, although the thighs, according to the doctors, can only be tightened if additional fat is extracted beforehand.

The health insurance company only rejected this after more than five weeks. However, she said that at least liposuction, the so-called liposuction, was obviously outside the range of benefits offered by statutory health insurance.

The BSG disagreed. After that, this argument usually no longer applies if the health insurance company has obtained an MDK report. This was the case here. The expert opinion showed that the cash register was also unsafe and saw a need for clarification, the Kassel judges argued.

In addition, the patient was allowed to trust the assessment of her doctors, the BSG continued. However, it emphasized that this no longer applies to purely cosmetic operations - such as the breast. It is common knowledge that health insurance companies do not pay for this. However, the specific case was “in the border area between physical complaints, psychological suffering and cosmetics”. mwo / fle

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