BGH: Glasses are only aids and not a healing treatment
Private health insurance companies have to pay for the laser eye surgery if an ametropia clearly affects reading and driving. This was decided by the Federal Court of Justice (BGH) in Karlsruhe in a judgment announced the previous day on Thursday, March 30, 2017 (file number: IV ZR 533/15). The insurers cannot refer to glasses afterwards because this is only an aid but not a treatment.
Around 140,000 so-called Lasik operations are performed in Germany every year - and the trend is rising. Defective vision of up to eight diopters can be corrected using laser beams.
In the case now decided by the BGH, a short-sighted woman from Baden-Württemberg had “lasered” her. It previously had minus 3.0 and minus 2.75 diopters. She claimed the cost of the treatment of 3,500 euros from her private health insurance. The latter refused.
The insurance conditions here correspond to the model conditions of private health insurers. "An insured event is the medically necessary treatment for an insured person because of illness or the consequences of an accident," it says.
An expert commissioned by the Heidelberg District Court stated that it was not possible to speak of an “illness” here. A certain degree of ametropia is completely normal in middle and older age. According to international standards, a morbid condition of the eyes is only spoken from minus 6.0 diopters.
Heidelberg District Court and District Court therefore dismissed the lawsuit. The BGH now overturned these judgments and agreed with the plaintiff.
As justification, the Karlsruhe judges emphasized that "understanding in medical circles" is not the yardstick here. Rather, what matters is "the understanding of an average policyholder".
This assumes, however, "that normal vision is accompanied by trouble-free reading and safe participation in road traffic". If these skills are significantly impaired, policyholders would therefore assume that they are ill. According to the expert opinion, this is also the case here.
The BGH emphasized that the insurers could not refer to a Bille or contact lenses. It is common to wear visual aids. However, these are not curative treatments, but "only aids". The insurance conditions did not make the reimbursement for necessary medical treatment dependent on whether the policyholder can also use medical aids instead. mwo / fle