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Health insurance companies do not have to pay for special diagnostic services abroad
The statutory health insurance companies do not have to pay the treatment costs for special diagnostics abroad. A plaintiff had previously had a cancer diagnosis carried out by a Dutch doctor and then applied for the costs with his health insurance company. The cash register had denied the assumption of the diagnostic costs. The patient then went to court.
Statutory health insurance companies do not have to pay the special costs for examinations abroad, judge the first Senate of the State Social Court of Hesse. The health insurers only have to pay for treatments or examination methods that are also recorded in the statutory benefits catalog. There are exceptions to life-threatening diseases, but only if there are no reasonable alternatives available that "meet the generally recognized medical standards," the judges said. The judges expressly emphasized that there was no claim to "top-class medicine at any price".
In this specific case, a 74-year-old man from southern Hesse had special MRI diagnostics carried out in 2005, which is only offered by a Dutch doctor. With the so-called USPIO-MRT, even tiny lymph node metastases can be identified using tiny iron particles, which other diagnostic procedures avoid. The diagnosis costs totaled 1,500 euros.
The health insurance company rejected a corresponding application for reimbursement of the costs on the grounds that "special diagnostics is not a contractual service". However, the plaintiff emphasized that the investigation "avoided surgery that was likely to have resulted in incontinence and impotence." However, the court rejected the complaint on the grounds that health insurance companies do not have to pay everything to maintain or Serve to restore health. Rather, health insurance policies are based on the prescribed benefit catalog (file number: L 1 KR 298/10). The state social court did not approve an appeal. (sb)
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