Cash benefit despite private treatment

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State Social Court of Hesse: Cash benefit despite private treatment if the doctor did not clearly indicate the private benefit

In a recent ruling, the State Social Court in Hesse ruled that private medical therapies must be covered by the statutory health insurance if the doctor treating the patient did not inform the patient beforehand.

In principle, health insurance patients can only claim medical services if they are listed in the service catalog of the statutory health insurance companies. All other treatments must be paid for out of pocket and therefore apply to so-called IGEL services. If a doctor advises his patient about a therapy that is not listed as a benefit, the patient must inform the patient about this. If the patient is not informed, he has to pay the costs himself. A man from Frankfurt am Main has filed a lawsuit against this practice of cost-pushing and was partially awarded the right by state social judges.

In the specific case, a widower complained, whose already deceased wife was referred to the university clinic in Frankfurt due to an intestinal cancer. A special cancer therapy was undertaken there, but is not listed as a health insurance benefit. The deceased's family doctor prescribed the cancer treatment without indicating that it was private medical treatment. The patient signed a form for private treatment on site. The clinic later billed for the therapy. In addition, a different form of therapy was used for the cancer patient than that prescribed by the family doctor. After the hospital treatment, the woman made a claim for reimbursement from her health insurance company. The fund refused to assume the costs and argued that the benefits were not subject to reimbursement. The procedure carried out is not recognized by contract law, as stated in a letter of refusal. A previous complaint by the patient was rejected by a social court in 2008. The applicant then appealed to the Hesse State Social Court. Since the applicant died of the consequences of her illness, the husband took over the action as heir.

The judges at the State Social Court saw the matter as a whole more differentiated. The doctor's obligation to provide information that has not been fulfilled must be borne by the health insurance company. In addition, according to the husband, the deceased had not even been aware that the treatment was different from the one that was actually prescribed by the family doctor. According to the court, the signed form was inadequate because it was not immediately apparent at the time that it was a non-reimbursable benefit from the statutory health insurance. (File number: L 8 KR 313/08)

The plaintiff was only able to achieve partial success. Although the health insurance company was ruled to pay the treatment costs of a total of 18,500 euros, the husband, as heir, must bear the largest part of the costs. Because even though the patient was informed by the health insurance company's rejection notice that cancer therapy was not part of the spectrum of statutory health services, the special treatment was continued at the time. In the period that followed, another whopping 50,000 euros were added. According to the reasoning of the judgment, the plaintiff now has to pay the costs himself. Only the period before the letter has to be reimbursed by the cash register.

The judgment is not yet final, because the defendant health insurance company has now applied to the Federal Social Court for revision. No wonder, since otherwise health insurance companies could face millions of euros in future if doctors do not clearly refer to the aspect of private treatment. It remains incomprehensible why the family doctor or the clinic are not made responsible. This aspect was irrelevant in the reasoning of the judgment. (sb)

Image: HHS /

Author and source information

Video: ICICI Lombard HospiFund policy. ICICI Lombard hospital cash benefits. Health Insurance


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