Full three weeks decision time for health insurance companies

LSG Munich: Mail delivery time is not to be offset against the deadline
(jur). The statutory health insurance companies have a full three weeks to decide on the insured person's claim for benefits. It is sufficient if the health fund sends the decision within this period, as the Bavarian State Social Court (LSG) in Munich decided in a decision announced on Wednesday, May 25, 2016 (file number: L 5 KR 121/16 B ER). The postal term is not to be counted towards the deadline.

According to the law, the health insurance companies have to decide on an application for benefits "quickly, at the latest within three weeks". If an opinion from the Medical Service of the Health Insurance Funds (MDK) is required, the health insurance fund must inform the applicant of this and the deadline is extended to five weeks. There are longer deadlines for dental treatments. If the fund cannot meet these deadlines, it must also inform the insured. "If no reason is given, the service is considered approved after the deadline".

The BSG recently decided that a health insurance company could then grant a service “by silence”: if the insurance company did not respond within the three-week period, the application was considered “fictitiously approved” (judgment and JurAgentur report of March 8, 2016, Az. : B 1 KR 25/15 R). The only requirement is that the requested benefit is part of the scope of the statutory health insurance and that the insured person can assume the consent of his health insurer. The cash register was then no longer entitled to carry out a further check.

The case now decided by the LSG Munich is about providing an insured person with a drug that is actually not approved for his illness. The health insurance company had rejected the application within three weeks, but the insured person received the letter two days later.

Nevertheless, the health insurance company met the deadline, judged the LSG Munich. The legislator wanted to give the health insurers a full three weeks to make their decision. This period is therefore “not shortened by mail delivery times. The health insurance companies do not bear the risk of delayed mail delivery either, according to the LSG in its urgent decision of April 25, 2016. mwo / fle

Author and source information

Video: Part 1 Coronavirus: the future after furlough (January 2022).