Karlsruhe. Those with private health insurance must pay out of their own pocket for rectal stimulation therapy with biofeedback training performed at home. The Federal Court of Justice (BGH) ruled in a ruling published on July 16 that there is no objection if a private health insurer makes reimbursement of the costs of the medication conditional on a “practitioner” who performs the therapy under the terms of his insurance. The Karlsruhe judges therefore saw no reason to uphold the appeal.
After an operation for anal fistula and perineal abscess, the author, who had a private health insurance plan, was prescribed electrotherapy with biofeedback training by the attending physicians. The therapy performed independently at home should strengthen the anal sphincter. The electrostimulation device required for this must be rented or purchased. Additional costs are incurred when purchasing the electrode. The health insurance company refused to cover the costs and referred to the conditions of its insurance.
This is not questionable, the BGH ruled. On the one hand, this is not a benefit that must be reimbursed. The insurance conditions stipulate in a final catalogue of benefits which benefits will be reimbursed. The electrostimulation block is not one of them. According to the BGH, assuming the costs can be considered a solution. However, this only applies if they are provided by a “practitioner”. These include doctors, dentists, alternative practitioners, medical lifeguards and state-certified masseurs. If the therapy is carried out independently at home by the insured person, there is no “practitioner”. Reimbursement of the costs is then out of the question. Private health insurance is generally allowed to limit the insurance benefits as part of its free business decision. The relevant clauses are also drafted in a transparent manner for the insured person. (fl)
Federal Court of Justice, Ref.: IV-ZR 216/23