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LSG Celle: Health insurance must first cover costs
Celle (jur). If disabled pupils apply for the cost of accompanying them to school, responsibility disputes between social welfare providers and health insurers must not be carried out on the back of the person concerned. This was decided by the State Social Court (LSG) of Lower Saxony-Bremen in a decision announced on Tuesday, May 9, 2017, and thus obliged a health insurance company to take over the provisional costs in an urgent procedure (file number: L 4 KR 65/17 B ER).
In the legal dispute, a pupil with multiple disabilities and suffering from epilepsy had applied to the Wittmund district for the cost of any necessary accompaniment to school. A degree of disability of 100 was recognized for the disabled and helpless pupil.
However, the district did not want to pay and rejected the application. Not he, but the health insurance company is responsible. Because the student regularly suffers from epileptic seizures, even while traveling to school. The accompaniment to school is therefore necessary for medical reasons. The social welfare institution therefore forwarded the application for cost reimbursement to the health insurance company.
But even this did not want to pay the costs. She was not responsible, since the accompaniment to school was not medical help, but "supervision to ensure the student's participation in education and training". This means that the social welfare agency is obliged.
In its decision of March 13, 2017, the LSG now obliged that the health insurance company must first assume the costs. It is indeed a matter of social welfare, for which the district must take responsibility. The dispute between the individual providers should not be at the expense of the severely disabled student.
According to the LSG, the pupil is entitled to general school education and thus to the accompaniment to school that is necessary for him. In the case of the dispute over jurisdiction here, the second carrier, i.e. the health insurance, is obliged to assume the costs. The latter can then get the money back from the social welfare institution. fle / mwo