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If a health insurance company takes too long to decide whether to apply for reimbursement for a mother-child cure, the application is considered “notionally approved”. If the medical service of the health insurance companies (MDK) is commissioned to examine the assumption of costs, the health insurance company has only five weeks to decide on the application, the State Social Court (LSG) North Rhine-Westphalia emphasized in a recently published decision of March 27, 2017 ( Ref .: L 1 KR 702/16). It does not matter for the assumption of costs whether the insured has already made advance payments for the measure, the Essen judges with reference to the legal provisions and the case law of the Federal Social Court (BSG) in Kassel.
According to the law, health insurance companies have to decide on an application for benefits "quickly, at the latest within three weeks". If an opinion from the MDK is required, the health fund must inform the applicant of this and the deadline is extended to five weeks. If the fund cannot meet these deadlines, it must also inform the insured.
In the case that has now been decided, on June 22, 2015, a mother applied to her health insurance fund for a mother-child cure. The health fund informed the woman that she had forwarded the application to the MDK.
On receipt of the MDK report, the health insurance company refused to cover the costs of the measure on August 3, 2015, and therefore only after more than five weeks. The woman had already received a mother-child cure in the past four years. Another cure during this time is only possible for urgent medical reasons, which are not available here, according to the reasoning.
The LSG obliged the health insurance to pay the costs. Because the cash register did not decide on the application within the five weeks prescribed here. This application was therefore deemed to have been approved.
The health insurance company had unsuccessfully argued that the fiction of approval could only apply to applications for which insured persons had already made advance payments. This was not the case here with the mother.
However, the Essen judges referred to the case law of the BSG. From the judgment of the top social judges of March 8, 2016 (file number: B 1 KR 25/15 R; JurAgentur report from the day of the judgment) it is clear that the fiction of approval also applies if the insured person has not yet paid in advance for the benefit is. Otherwise, poor insured persons who do not have this financial opportunity would be disadvantaged. fle / mwo / fle