Health insurance benefits can also be passed through silence

Health insurance benefits can also be passed through silence

Kassel (jur). If the cash register does not respond within three weeks, the application is considered “fictitiously approved”, judged on Tuesday, March 8, 2016, the Federal Social Court (BSG) in Kassel (file number: B 1 KR 25/15 R). The only prerequisite is that the requested benefit is part of the scope of the statutory health insurance and the insured person was able to assume that his health insurance fund had approved it.

Specifically, the miners' health insurance company was obliged to pay an insured person 24 sessions of psychotherapy based on depth psychology. The 31-year-old had applied for benefits on the advice of his therapist following a short-term therapy taken over by the health insurance fund. The miners had obtained an MDK report, but had not informed the applicant of this. The rejection came only after almost six weeks.

Meanwhile, the man had started therapy with 24 sessions, but for his own account. He now requested reimbursement from the health insurance company in the amount of 2,200 euros.

According to the law, the health insurance companies have to decide on an application for benefits "quickly, at the latest within three weeks". If an opinion from the Medical Service of the Health Insurance Funds (MDK) is required, the health insurance fund must inform the applicant of this and the deadline is extended to five weeks. There are longer deadlines for dental treatments. If the fund cannot meet these deadlines, it must also inform the insured. "If there is no notification of a sufficient reason, the benefit is deemed to have been approved after the expiry of the deadline," it says literally in the Social Code.

Nevertheless, the miners said that the deadlines should not lead to insured persons receiving benefits to which they are not entitled. Otherwise, abuse is "opened the door". After all, the health insurance companies are committed to profitability.

The BSG did not accept this argument. The legislator's goal was to provide prompt care. The miners did not respond to their insured for more than three weeks. Therefore, the application for benefits is considered "fictitiously approved".

The other only applies to applications that are obviously outside the health insurers' obligation to pay benefits. Here, however, the insured person could have assumed approval because his therapist had also approved the therapy. The miners therefore had to pay the costs for the therapy hours they had procured themselves, the BSG judged. (mwo / fle)

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