The priority of outpatient treatment over inpatient treatment, which is regulated for statutory health insurance companies in § 39 (1) sentence 2 SGB V, is always a topic of discussion in Germany… moreover If this applies to private health insurance companies!
It is no news that insurance companies often have problems with the assumption of the treatment costs. A particularly interesting case was discussed this year at the Regional Court of Mannheim (10.09.2020; 9 O 383/19).
2014: a private patient has to spend three weeks in the hospital and after his obligatory stay it has to be discussed whether the health insurance company or himself has to pay the costs of the treatment. The stay in the clinic resulted in costs of over 8,000 EUR and the German health insurer refused to cover the costs on the grounds that outpatient treatment of the illness would have been sufficient. It referred to the principle applicable in the statutory health insurance system in Section 39 I sentence 2 SGB V that outpatient treatment has priority over inpatient treatment. This principle also applies to privately insured persons. The policyholder saw this differently and therefore brought this case to court. He argued that there was no such priority for private health insurance companies.
The decision of the Mannheim Tribunal is clear: no right to reimbursement of costs for inpatient treatment.
The plaintiff was not entitled to the assumption of costs by the health insurer, as the medical necessity of the in-patient treatment could not be clearly established and demonstrated. In-patient hospital treatment is only medically necessary if the desired success cannot be achieved with an out-patient measure. Unfortunately for the private patient, this was not the case.
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