Judgments: Cancellation of sickness benefit due to non-commenced rehabilitation

Judgments: Cancellation of sickness benefit due to non-commenced rehabilitation

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Cancellation of sickness benefit due to non-commenced rehabilitation
Stuttgart (jur). If a health insured person does not start an approved rehabilitation measure without justification, the sickness benefit can be canceled. Because the insured person is obliged to cooperate here, the Baden-Württemberg State Social Court (LSG) in Stuttgart decided in a recently published judgment of June 21, 2016 (file number: L 11 KR 455/16).

In the specific case, the plaintiff was on sick leave on December 10, 2010 because of a mental illness. His health insurance paid sickness benefit after the employer continued to pay the salary. The employee was finally fired on April 1, 2011.

According to an opinion of the medical service of the health insurance companies (MdK) the employability of the insured was endangered. He was therefore asked at the end of 2011 to submit an application for medical rehabilitation. The rehabilitation measure was also approved by the pension insurance institution. But the man did not start rehab without giving a specific reason.

As a result, the health insurance company refused to pay sickness benefits. Only for compelling reasons can an insured person postpone or cancel a medically necessary and appropriate measure.

Only in the lawsuit did the man state that the rehabilitation clinic was 511 kilometers away from his place of residence. He would have had to take the train there at night to be able to arrive at the clinic on time from 10 a.m. to 12 p.m. This is unreasonable.

The LSG ruled that insured persons were obliged to participate. If a rehabilitation measure has been approved, it must actually be started. Sickness benefits can therefore be refused or withdrawn “until the participation is made up for in full or in part”.

Normally, the health insurance company would have to make a discretionary decision if the sickness benefit was refused. Here, however, this was not necessary because the insured person had given no reason for not starting rehabilitation. He was also advised of the consequences if he did not appear in the rehab clinic. The fact that the insured person had to take the train to rehab at night so that he would arrive there punctually the next day was not an "important reason" to forego the measure. fle / mwo

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