The initial situation: treatment in an expensive private clinic
An insured person was treated in a renowned private clinic and submitted the treatment costs to his private health insurance company for reimbursement. The clinic was known for its high costs, which were significantly higher than those of public hospitals. The insurer refused to cover the full costs on the grounds that the treatment costs were disproportionate to the services provided and that the insured person could have been treated in a cheaper public hospital without compromising the quality of medical care.
The insured then sued for full reimbursement of the treatment costs. The case eventually went before the Federal Court of Justice (BGH), which had to deal with the question of under what conditions private health insurers are obliged to cover hospital costs.
The decision of the BGH: What was decided?
In its ruling of March 12, 2003, the Federal Court of Justice ruled in favor of the insured, stating that private health insurance is in principle obliged to reimburse even if treatment takes place in a more expensive private clinic (case no. IV ZR 278/01). In its ruling, the Federal Court of Justice emphasized: “The insurance company is obliged to cover the costs of medically necessary treatment, even if this takes place in a private clinic and the costs are higher than those of a public hospital.” This statement underlines that insured persons are not automatically limited to the most cost-effective treatment if there is a medical necessity for the more expensive option.
The ambiguities: What remains vague?
Despite this clear requirement, the ruling leaves room for interpretation, particularly with regard to the “appropriateness” of the costs. The BGH also stated: “Insurance companies are not obliged to cover costs that are disproportionate to the benefits provided.” However, it remains unclear how exactly the appropriateness of the costs should be assessed in practice. This could lead to insurance companies applying different standards, which in practice could lead to varying reimbursement decisions.
Insurers could, for example, argue that the costs at a more expensive clinic are disproportionately high, especially when cheaper alternatives are available that they consider to be medically equivalent. Since the ruling does not set out detailed criteria for when costs are considered reasonable, the decision on reimbursement often remains at the discretion of the insurers.
The role of medical necessity: A central point
Another important aspect of the ruling is the “medical necessity” as a prerequisite for the reimbursement of higher costs. The BGH made it clear that a private health insurance company is obliged to reimburse “if treatment in a more expensive clinic is medically necessary.” This point is crucial, but here too there could be different interpretations in practice.
Insured persons must prove that the choice of the more expensive clinic is not based on personal preferences, but on objective medical reasons. Without clear guidelines on what is considered “medically necessary,” insurance companies could interpret this necessity differently, which can lead to uncertainty among insured persons.
Impact on insurers: audit rights and scope for interpretation
The ruling grants the insurance companies considerable audit rights. The BGH stated: “The insurance company is not obliged to reimburse excessive or inappropriate costs if less expensive, equivalent treatment is available.” This wording gives insurers the opportunity to evaluate not only the actual costs but also possible alternatives.
However, since no precise criteria for “excessive” costs or “reasonableness” have been defined, it is often at the discretion of insurers to assess whether reimbursement is justified. In practice, this can lead to reimbursement decisions varying depending on how the insurer assesses the specific case.
Conclusion: An important but partly vague judgment
The BGH ruling provides important clarifications regarding the reimbursement of costs by private health insurers, but leaves room for interpretation in some areas. While the ruling strengthens the rights of insured persons by giving them more freedom in choosing expensive treatment facilities, the precise assessment of “appropriateness” and “medical necessity” often remains unclear in practice.
These ambiguities could mean that insured persons have to carefully document their claims in order to receive full reimbursement. At the same time, insurance companies have the opportunity to examine reimbursement claims comprehensively and, if necessary, to restrict them. Overall, this is a groundbreaking ruling, but one that allows for different interpretations in its practical application. The ruling is available on the website of the Federal Court of Justice.
