Oldenburg Social Court, 01.06.2011, Ref.: S 61 KR 354/09
Insured persons in the statutory health insurance scheme often have to make co-payments when utilising medically prescribed treatment, Section 61 SGB V.
Currently, the annual limit per family is two per cent of the gross family income. In the case of insured persons who are undergoing long-term treatment for a serious chronic illness, the annual limit is only one per cent.
From the Additional payments A distinction must be made between the payment of the Own contribution by the insured person. The background to this co-payment is the fact that some medically prescribed aids are everyday items that are also used by healthy people. The insured person must then pay the co-payment for this part of the medical aid. In the case of orthopaedic shoes, for example, the shoes are an article of daily use, but the orthopaedic "fitting" is the medical aid.
In the above-mentioned decision of the Social Court of Oldenburg, the court had to decide whether the defendant health insurance company was obliged to pay the plaintiff's own contribution for so-called orthotic shoes.
Case Background
The plaintiff, born in 2006, was dependent on orthotic shoes due to a disability and was insured with the defendant. The defendant had approved the costs for the special shoes, but the plaintiff had to pay a co-payment of 45 euros per pair of shoes, totalling 90 euros. The plaintiff's mother asked the insurance company to review the co-payment, as her son frequently needed new shoes due to his illness. The defendant refused to cover the costs in full and pointed out that the insured person had to pay a personal contribution for the item of daily use, in this case shoes.
Objection and Lawsuit of the Plaintiff
Following the rejection by the insurance company, the plaintiff lodged an objection, which was also rejected. The defendant's reasoning was based on the fact that the co-payment for orthopaedic street shoes was 45 euros in accordance with the joint recommendation of the umbrella organisations. The plaintiff then brought an action before the Oldenburg Social Court, arguing that the case was a rehabilitation case under SGB IX and that the defendant had wrongly examined the case in accordance with the provisions of SGB V. The plaintiff argued that the defendant should have forwarded the case to the social welfare organisation.
Judgement of the Oldenburg Social Court
The Social Court ruled in favour of the defendant and declared that the notices were lawful. Section 13 para. 3 SGB V was the sole basis for the assumption of the personal contribution, according to which the health insurance fund was only obliged to reimburse costs if it had wrongly refused a benefit. As the rejection of the personal contribution was considered correct, these conditions were not met. Although the plaintiff was entitled to orthotic shoes as an aid, he had to take into account the general benefit of using the shoes, as they are also used by healthy people.
Legal justification and own contribution
The court stated that an economic separation is necessary for aids that are also items of daily use. The insured person's own contribution should correspond to the value of the general commodity, in this case normal children's shoes. The court confirmed that the personal contribution of 45 euros was appropriate and was at the lower end of the usual costs for children's shoes. Full assumption of costs by the defendant was therefore not justified, as the insured person should not be relieved of expenses that everyone has to bear. It was also not necessary to transfer the case to the social welfare organisation, as the defendant had acted correctly as a rehabilitation provider.
Source: Social Court Oldenburg
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One Response
What is the situation for adults? Our health insurance company is convinced that disabled people who have reached the age of majority must also bear the full cost of orthotic shoes. Only in very rare exceptional cases would the health insurance fund cover the cost of the shoes (minus the personal contribution).