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Privately insured patients have the right to inspect the medical opinions in their insurance records
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Private health insurance companies often refuse to cover treatment on the grounds that it is not medically necessary.
This non-necessity argument is routinely justified with medical opinions of allegedly
`neutral medical experts´ commissioned by the insurance company to evaluate the patient's treatment records.
In the majority of cases, the expert prepares the medical opinion without ever having personally examined
the patient.
The `Bundesgerichtshof (BGH)´ [German Supreme Court of Justice] has now put a stop to this practice. In the
opinion of the BGH, private health insurers must present the medical opinions they have commissioned to a health
care specialist specified by the patient and they must identify their medical expert, even if no physical
examination was made.
Article §178m of the `Versicherungsvertragsgesetz (VVG)´ [German Insurance Contract Act] states that the patient
has the right to inspect medical opinions commissioned by the insurer if the patient was physically examined as
part of preparing the opinion.
Private insurers have always interpreted the wording of article §178m literally and refused to grant inspection
of the medical opinion on the grounds that no physical examination took place.
The BGH takes the view that only when the patient has complete knowledge of the medical opinion is the patient
in the position to be able to assess whether he is entitled to reimbursement of treatment costs and whether legal
proceedings stand a chance of success (Case: IV ZR 418/02).
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Privately insured patients can freely choose their treatment methods
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The Bundesgerichtshof pronounces a customer-friendly judgment. Privately insured patients are free to choose
their preferred treatment method.
If it's an accepted therapy, then private health insurers must pay for it. This is the patient-friendly judgment
recently pronounced by the Bundesgerichtshof (Case:IV ZR 278/01).
The common practice of insurance companies has been to require economic appraisals, which have time and again led
to sometimes enormous cuts in what insurers have paid toward doctor's and hospital bills.
In the opinion of the BGH, privately insured patients have the right as per the usual insurance policy terms and
conditions to receive the best possible medical treatment unless the policy expressly excludes certain services.
The BGH takes the view that non-expert laypersons must be able to understand the clauses of the insurance policy.
The Court is the opinion that wording such as: ´as far as medically necessary´ does not implicitly state that
the patient is obligated to choose only the cheapest treatment method available.
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We are always at your service to answer
any further questions you may have:
+ 49 (0)9 41 54 218
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Orthodontic Practice in Regensburg Dr. Kathrin Falkenstein
Modern Orthodontics · Lingual Treatment · Gentle Orthodontics
Invisible Braces · Analysis of the Temporomandibular Joint · Microimplants
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