Health insurance: No full international costs

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Health insurance companies do not have to fully cover treatments abroad

The Federal Social Court in Kassel has ruled that German health insurance companies only have to pay treatment for their members abroad to the same extent as would have been the case with comparable treatment in Germany (file number B 1 KR 14/09 R). The case: A man born in 1939, who is permanently resident in Germany and has statutory health insurance from a replacement fund, underwent one operation at the heart valves in a London clinic in 1982 and 1992, whereby he received a so-called "bioprosthetic" Aortic valve "ie a heart valve consisting of tissue from deceased organ donors, was transplanted. In both cases, the man's replacement fund paid for the full amount, since the operations at that time would not have been possible in this country. In 2005 the plaintiff had to do it again had surgery carried out and, as in the previous cases, again applied for the costs to be borne - but unlike in the 23 or 13 years previously, the health insurance company was now only prepared to accept the payment pro rata and, moreover, only in "exceptional cases" The result: The substitute fund only took over the amount that would be due in a corresponding hospital in this country n would be (€ 24,000), which meant that the plaintiff had to pay € 12,000 of the total cost of the operation (€ 36,000).

The court now had to decide and, as mentioned at the beginning, judged the procedure of the health insurance company to be legal and also found that there was no claim that could justify the reimbursement of the full costs in an exceptional case.

The cost of the first two surgeries would have been covered entirely because the transplantation of bioprosthetic heart valves was not yet possible in Germany at the time. However, since this situation has changed in the meantime, it would also have been reasonable for the plaintiff to seek treatment here. The judges also rejected the man's objections that he trusted the doctors in the London clinic and that, in his opinion, he was treated better and with less risk there than would have been the case in Germany - on the one hand, it was not for the solidarity community acceptable to have to pay for special requests and on the other hand there would be no evidence for the assumed higher competence of the British doctors in the specialist literature. Therefore, the health insurance company would not be obliged to cover the full cost of such treatment. (Sb, 02/21/2010)

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