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Patient “pre-determination act” by treatment agreement

(Private) Surgery without insurance authorization: right of reimbursement?  

Federal Social Court, judgement of 27.10.2020 – B 1 KR 3/20 R

What happens if a person insured under the statutory health insurance scheme decide to proceed with a requested service herself before the decision period of the health insurance fund has expired?

In this real case, the patient was willingly to have a liposuction and decided not to wait for the health insurance decision of whether they should cover the expenses or not. According to § 13 para. 3a p. 1 SGB V, the health insurance is not entitled of reimbursement of the costs of the service that the woman decided to procured herself. Her action infringes § 13 para. 1 p. 7 SGB V. Whether or not the insurance company would have decided on reimbursing the client within the legal specified period of time is in this case irrelevant.

If an insured person procures the service herself, irrespective of its execution, it is to be considered as a private customer.

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Patient “pre-determination act” by treatment agreement

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