Federal Supreme Court Federal Court allows restriction of choice of doctor for uncoordinated treatments
The Federal Supreme Court has ruled that health insurers may appoint a first point of contact for the coordination of treatment if insured persons make use of uncoordinated medical services. This does not restrict the free choice of doctor.
11.11.2024, 12:00
SDA
In a landmark ruling, the Federal Supreme Court has decided that health insurers have the option of specifying a first point of contact for the coordination of treatment. This measure takes effect if insured persons make uncoordinated use of medical services and is in line with the Health Insurance Act.
In the present case, an insured person had repeatedly made use of uncoordinated medical services. Based on an expert opinion, the health insurer then ordered that future cost coverage under the compulsory health insurance scheme (OKP) should only be provided via an approved first point of contact.
This regulation was formulated by the Aargau Insurance Court in such a way that the health insurance company would only cover the costs of treatment that was either provided by the first point of contact itself or initiated by the first point of contact through a referral.
The Federal Supreme Court dismissed the insured person's appeal and confirmed that, in accordance with the Health Insurance Act, the OKP only covers the costs of services that are effective, appropriate and economical. Insurers are obliged to check these criteria and ensure that treatments are coordinated accordingly.
Coordination as the key to efficiency
The Federal Supreme Court's decision underlines the importance of coordination in the healthcare system. By establishing a first point of contact, the efficiency of medical care should be increased and unnecessary costs avoided. This is particularly relevant in cases where insured persons make use of medical services without a clear structure and agreement.
The measure aims to ensure the quality of care and at the same time reduce the financial burden on health insurers. By monitoring compliance with the criteria for effective, appropriate and economical services, insurers contribute to the stability of the healthcare system.
