Dispute over co-payments: Success for nursing home resident
The Federal Constitutional Court has strengthened the rights of a needy nursing home resident in a dispute with her health insurance company over co-payments. Specifically, the constitutional complaint concerned an excessive limit for co-payments. According to the highest German court in Karlsruhe on Friday, a decision by the Osnabrück Social Court, which had confirmed the view of the health insurance company, violated the ban on arbitrariness. An assumption contained in the court decision regarding the assumption of costs "lacks any comprehensible basis". It will be annulled and the social court will have to deal with it again (case no. 1 BvR 422/23).
People with statutory health insurance have to pay extra for some health insurance services. These co-payments are limited by a limit of two percent of annual gross income. People who receive certain social benefits have to make lower co-payments.
In this particular case, a social welfare provider reportedly pays part of the costs of the home for the woman, who was born in 1938. After deducting a monthly clothing allowance of 23.50 euros and an entitlement to 120.42 euros in cash, the remaining income should make up the monthly contribution to be paid.
According to the notification, the insured person applied to her health insurance company to limit her co-payments. This set a limit of 132.04 euros for 2022 based on the woman's pension income. The person concerned appealed against this. The health insurance fund rejected the objection, while the social court rejected the appeal.
At the heart of the dispute is the question of how an exception to the contribution limit in Section 62 of the Fifth Social Security Code is to be understood. The health insurance fund and the Social Court saw no reason to take this into account in the present case.
In its decision, the Constitutional Court made it clear that this view made no sense. "According to the wording of the regulation, the prerequisite for the facts of the case is that the social welfare provider bears the costs of placing the insured person in a home or other facility." Contrary to what was assumed by the health insurance fund and the social court, there is no evidence of further conditions.
The complainant was initially unsuccessful at the Lower Saxony-Bremen Regional Social Court, which was also involved in the case. According to this decision, she had argued that no other health insurance fund shared her fund's reasoning when it came to setting the limit. There was also no other known decision that dealt with the legal issue at hand.
- This case highlights the importance of justice in social affairs, as the Federal Constitutional Court overturned a decision that violated the ban on arbitrariness in the process of determining co-payments for a nursing home resident's health insurance and long-term care insurance.
- In the context of health insurance and long-term care insurance, finance management plays a significant role, as co-payments can significantly impact the overall financial situation of individuals, particularly in the case of nursing home residents.
- The debate over co-payment limits in health insurance policies can have far-reaching implications for long-term care, as individuals may struggle to afford necessary care services if co-payments exceed their financial means.
Source: www.dpa.com
