When health insurers don't pay for therapies

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When health insurers don't pay for effective therapies

Therapy costs are often not covered by the statutory health insurers because the effectiveness of the treatment is considered “not scientifically proven”, even though the patient's recovery has been started. The same happened to a patient who underwent immunotherapy after being infected 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 number: L 11 KR 2307/07).

Statutory health insurers can stay on the cost of treatment if the treatment is not considered "recommended" by the Federal Joint Committee (GBA). As the working group "Medical Law" of the German Lawyers' Association pointed out, the State Social Court of Baden-Württemberg has rejected a corresponding complaint by a patient, although insured persons of the statutory health insurance companies are entitled to treatment according to the law (§ 27 SGB V) if it appears necessary to diagnose, cure, alleviate or stop or slow the progression of the insured person's illness. Medical therapy also explicitly includes drug supply. But in the legal situation there is also a restriction that states that the health services correspond to the current scientific state of medicine in terms of their effectiveness and quality. Therapy from the fields of homeopathy, naturopathy and osteopathy are largely excluded, even if they provide the patient with relief from symptoms or even a cure for suffering.

In their communication, the lawyers refer to a judgment of the Baden-Württemberg State Social Court. The judges decided that treatment should reflect the current state of medicine in terms of quality and effectiveness. With newer treatment methods or diagnostic agents, this is only the case if the GBA recognizes the benefits of treatment.

In the specific case, the plaintiff suffered from the Epstein-Barr virus and underwent immune balance therapy to combat chronic fatigue. The relevant preparations were prescribed to the plaintiff by a doctor. The total cost of the funds sold as "food supplements" was 73,000 euros. The court found it proven that the preparations were not approved by the GBA. In addition, it would be food supplements, the costs of which are not covered by the health insurance companies anyway. In addition, there was no danger to life for the patient, which is why there was no emergency situation similar to an emergency. (sb)

Image: berlin-pics / pixelio.de

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