9C_108/2014 · Insured Person v. Health Insurer (Laboratory Tests for Complementary Therapy) (Bundesgericht)

Legislator-Zusammenfassung

KI-generiert

The case involves a dispute between an insured individual and a health insurance provider regarding the coverage of costs associated with laboratory tests ordered by the individual's doctor. The insured, born in 1940, had the tests performed in March 2010, which were billed at CHF 378.60. The insurance company later denied responsibility for payment, arguing that the tests were related to a non-mandatory alternative therapy. The insured contested this decision, leading to an appeal to the Social Security Court of Zurich that sided with the insurance provider and upheld the denial. Consequently, the insured appealed to the Swiss Federal Tribunal, seeking reimbursement for the laboratory costs and interest, asserting that the tests were essential for treatment. The court ultimately considered the relationship between the laboratory analyses and the proposed alternative treatment, determining that the insurer was not obligated to cover these costs under the standard health insurance provision.

Legislator-Regeste

KI-generiert

Art. 105 Abs. 1 BGG, Art. 95 BGG, Art. 105 Abs. 2 BGG, Art. 106 Abs. 1 BGG, Art. 25 Abs. 1 KVG, Art. 25 Abs. 2 lit. b KVG; Insured Person v. Health Insurer (Laboratory Tests for Complementary Therapy): The insured, born in 1940, had the tests performed in March 2010, which were billed at CHF 378.60. The insurance company later denied responsibility for payment, arguing that the tests were related to a non-mandatory alternative therapy. The insured contested this decision, leading to an appeal to the Social Security Court of Zurich that sided with the insurance provider and upheld the denial. Consequently, the insured appealed to the Swiss Federal Tribunal, seeking reimbursement for the laboratory costs and interest, asserting that the tests were essential for treatment. The court ultimately considered the relationship between the laboratory analyses and the proposed alternative treatment, determining that the insurer was not obligated to cover these costs under the standard health insurance provision.

Schlagwörter

KI-generiert

Krankenversicherung Deckung der Krankenversicherung medizinische Behandlung Kostenersatz Blutprobe Pflichtleistung Nährwert- und gesundheitsbezogene Angaben

Zitierte Gesetzesbestimmungen

KI-generiert

Art. 105 Abs. 1 BGG

Das Bundesgericht legt seinem Urteil den Sachverhalt zugrunde, den die Vorinstanz festgestellt hat ( Art. 105 Abs. 1 BGG ), und kann deren Sachverhaltsfeststellung von Amtes wegen nur berichtigen oder ergänzen, wenn sie offensichtlich unrichtig ist - wozu auch Unvollständigkeit gehört (Urteil 9C_395/2009 vom 16.

Art. 95 BGG

- oder auf einer Rechtsverletzung im Sinne von Art. 95 BGG beruht ( Art.

Art. 105 Abs. 2 BGG

95 BGG beruht ( Art. 105 Abs. 2 BGG ).

Art. 106 Abs. 1 BGG

Es wendet das Recht von Amtes wegen an ( Art. 106 Abs. 1 BGG ).

Art. 25 Abs. 1 KVG

Cited in the reasoning to establish what the mandatory health insurance covers, forming the background for analyzing the case concerning laboratory analyses.

Art. 25 Abs. 2 lit. b KVG

Cited in the reasoning as a basis for including covered medical acts, specifically prescribed analyses.

Art. 32 Abs. 1 KVG

Cited in the reasoning as the standard requiring medical services to be effective, appropriate, and economical.

Art. 28 KLV

Cited in the reasoning in conjunction with KVG articles to confirm that the analyses corresponded to positions in the list of benefits.

Zitierte Rechtsprechung

KI-generiert

9C_395/2009

Pension Fund Denial of Vested Benefit Transfer Reversed Based on Social Security Employment Definition

BGE 134 V 250

Rental Income from Inherited Business Assets: Self-Employment Income Subject to AHV Contributions

BGE 120 V 200

Swiss Federal Insurance Court Ruling on Health Insurance Coverage for Psychosomatic Treatment in Medical Centers

BGE 138 III 359

Abusive Dismissal of Employee Representative: Economic Reasons vs. Justified Cause

BGE 130 V 532

Mandatory Health Insurance Coverage for Off-Label Chemotherapy Use

9C_477/2011

Swiss Invalidity Insurance vs. Insured Person (Cochlear Implant Coverage)

KI-generiert

K 92/04

Insured Person v. Health Insurer (Preventive Cancer Screening Coverage)

K 1/06

Insured vs. Health Insurer: Coverage for Avant-Garde Treatment Abroad

U 44/04

Claimant v. Insurer (Benefits Cessation and Expert Evidence Sufficiency)

K 17/05

Insured vs. Health Insurer on Extended Psychotherapy Coverage

BGE 108 V 253

Insured Person v. Health Insurance Fund Regarding Acupuncture Reimbursement

Zentrale Rechtsfragen, extrahiert von Legislator

KI-generiert

Art. 66 Abs. 1 BGG

The primary procedural rule applied in the dispositive to order the appellant to bear the court costs due to the outcome of the case.

Art. 25 Abs. 2 lit. b KVG

Cited in the reasoning as a basis for including covered medical acts, specifically prescribed analyses.

Art. 25 Abs. 1 KVG

Cited in the reasoning to establish what the mandatory health insurance covers, forming the background for analyzing the case concerning laboratory analyses.

Art. 26 KVG

Cited in the reasoning to discuss the restrictive conditions under which preventive services are covered.

Art. 32 Abs. 1 KVG

Cited in the reasoning as the standard requiring medical services to be effective, appropriate, and economical.

Art. 33 Abs. 2 KVG

Cited in the reasoning in conjunction with KLV articles regarding the analysis list.

Art. 33 Abs. 1 KVG

Cited in the reasoning when discussing the presumption of coverage for medical treatments.

Art. 44 KVG

Cited in the reasoning to contrast mandatory benefits with complementary medicine services, which are not covered by tariff protection.

Art. 52 Abs. 1 lit. a Ziff. 1 KVG

Cited in the reasoning in conjunction with KLV articles regarding the analysis list.

Art. 33 lit. a KVV

Cited in the reasoning regarding the mandate of the negative list (Annex 1 KLV).

Art. 12 bis bis KLV