Leistungsverweigerung der gesetzlichen Krankenversicherung - anwaltliche Strategien

Abstract

The article presents some strategies that have been either tested or are worthy of consideration in a dispute conducted through lawyers with health insurance funds when benefits are unjustifiably denied to insurance holders. There are hardly any satisfactory legal instruments which can be used against the tardy examination of benefit claims by health insurance funds. What could be considered here is an assertion of default interest. The reimbursement of costs can only be considered in the event of a final refusal by the health insurance fund or in the case of benefits that cannot be postponed. At any rate, a decision on the part of the health insurance fund should be enforced and the results awaited. The consequences of the decision of the Federal Constitutional Court of 5.12.2005 are presented in brief. The relationship between the doctor and the medical service of the health insurance fund (MDK) is discussed. In the event of a benefit review by the MDK, the prescribing doctor has therapeutic latitude vis-a-vis the health insurance fund and the reviewing doctors of the MDK. All that the MDK does here is check justifiability. The insured person's right to choice in terms of the implementation of the benefit in a particular therapy centre is subject to the suitability of the facility and to affordability. According to the practice of the social security courts, it is also subject to the contractual connection of the facility to the insurance body responsible. Then there is a brief examination of claims for damages by insured parties and the right to action of the public service provider.