LSG Essen: Social welfare office must be informed immediately
If a clinic provides emergency help for an uninsured patient, it must inform the social welfare office immediately that the treatment costs will be covered. The State Social Court (LSG) of North Rhine-Westphalia in Essen decided on 7 September 2016 that the hospital would only be able to have the costs reimbursed in the event of a medical emergency, at least for these days of treatment, if the social assistance provider is not available, for example on a weekend published judgment (Az .: L 9 SO 328/14). The clinic can only claim the full flat rate per case if the social welfare office finally approves the costs and the patient needs help.
The plaintiff, a clinic for vascular surgery, thus remains largely at the cost of almost 30,000 euros for emergency treatment provided to an uninsured patient from Kenya.
The Kenyan had traveled to Germany for a language course. A German couple he knew had promised to bear the costs of living and leaving the country. ADAC travel health insurance was taken out for the man. When the Kenyan met a German, but the latter rejected his marriage proposal, he jumped from the third floor of an apartment building with the intention of suicide.
He seriously injured himself, among other things on the main artery. The man was admitted to the clinic for vascular surgery on December 20, 2009, a Sunday, as an emergency. It was only on Tuesday that the local social welfare office applied for the treatment costs to be paid by fax.
The authority refused. The man's need for help was not proven. In addition, the clinic only applied for reimbursement of costs on Tuesday, too late. However, assumption of costs is only possible with prior assurance from the authority. Only in a partial judicial settlement did the social welfare office agree to pay just under 3,900 euros.
Since the patient, who had meanwhile left for Kenya, had acted with the intention of suicide, travel health insurance also refused to cover the costs. The German couple also did not want to pay because they only wanted to pay for costs incurred by the state authorities.
In its decision of August 18, 2016, the LSG decided that the clinic could not demand that the remaining costs of just under EUR 26,000 be borne. According to the LSG, a hospital can request the social welfare office to cover the treatment costs for an uninsured patient in an emergency. However, the social welfare office had to be informed about this in "appropriate time" and the reimbursement of costs had to be approved. However, this was not the case here.
There is an urgent case in which the authority cannot be informed immediately, such as on a Sunday, but a cost reimbursement "to the extent" for the treatment can be requested for this time without the consent of the social welfare agency. Thereafter, based on the case flat rate, a daily, proportionate remuneration had to be paid by the social welfare office, according to the LSG. The proportional remuneration for Sunday is covered by the 3,900 euros paid by the social welfare office. The clinic unsuccessfully claimed that it had performed the most cost-intensive services on the patient's day of admission, and therefore had to pay higher compensation. fle / mwo