Health insurance companies may coordinate treatments Federal Court restricts free choice of doctor

A health insurance company may appoint a first point of contact for the coordination of treatments if insured persons make use of medical services in an uncoordinated manner. This was decided by the Federal Supreme Court.

A health insurance company may appoint a first point of contact to coordinate medical treatment for a person if the insured person makes use of medical services in an uncoordinated manner. This was decided by the Federal Supreme Court. The free choice of doctor and the system of compulsory benefits are compatible with such a gatekeeper.

In the specific case, an insured person made use of various uncoordinated medical services, mainly in the psychiatric field. She had taken out the standard insurance model with free choice of doctor with her health insurer, according to a ruling by the Federal Supreme Court published on Monday.

In connection with a measure requested by the insured woman for the treatment of obesity, the health insurance company had an expert opinion drawn up by a specialist in psychiatry and psychotherapy as well as neurology at the Medas medical assessment institute.

Emergencies excluded

Based on the report and an assessment by a medical consultant, the health insurer issued an order in February 2023 for the future assumption of costs under compulsory health insurance (OKP).

The regulation was formulated by the Aargau Insurance Court in 2023 in such a way that the health insurance company would only have to cover the costs of services provided by an approved first point of contact - a so-called gatekeeper - itself. Treatments arranged by the gatekeeper by means of referrals to third parties were also to be covered by the health insurance fund. Emergencies and gynecological check-ups were excluded.

The Federal Supreme Court dismissed the insured person's appeal against this decision. According to the Health Insurance Act (KVG), compulsory health insurance covers the costs of services that are effective, appropriate and economical. These are also known as the WZW criteria.

According to the Federal Supreme Court, insurance companies are obliged to check whether these requirements are met. In the present case, the health insurance company came to the conclusion that the complainant's previous uncoordinated use of medical services constituted an ineffective and inappropriate treatment method.

Free choice of doctor not affected

For this reason, a treatment plan by a leading medical institution as gatekeeper is appropriate. This procedure is compatible with the principle of free choice of doctor and the system of compulsory benefits, as the highest Swiss court writes in its considerations.

In the case of compulsory medical services, there is a legal presumption that they meet the requirements for cost coverage by the OKP. However, this presumption can be overturned by the health insurer.

The free choice of doctor is subject to the WZW criteria. This is not altered by the fact that the present case does not involve a single therapeutic measure, but an overall coordinated approach by means of a first point of contact.

Finally, the ruling did not constitute an unlawful interference with the complainant's fundamental rights. The Federal Supreme Court points out that the health insurance company's approach could also serve the interests of the insured persons themselves, who would thus be protected from medically objectively unnecessary treatments or interventions.

SDA