Health insurance companies have to pay Lucentis

Health insurance companies have to pay Lucentis

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AMD: Cash registers have to pay for Lucentis

Patients who need the medication "Lucentis" to treat age-related macular degeneration can have their costs fully reimbursed by their health insurance in the future. The Federal Social Court decided this in a recent judgment.

Macular degeneration can lead to loss of central vision. Age-related macular degeneration (AMD) is a very common eye disease among older people, which leads to loss of vision in the area of ​​the sharpest vision (macula). The medicine "Lucentis" from Novartis is often used to treat the disease, which is approved in a "single-use vial" and must be injected into the patient's eye by the doctor.

Medicinal product not yet listed in the "uniform evaluation standard" For many of those affected, however, it has been an expensive matter so far: Because injections into the eye have so far not been included in the remuneration system for medical care, the "uniform evaluation standard", those insured by law have so far only been able to bill treatment privately . Accordingly, the syringes had to be paid for first, then the cash register could decide how much the costs would be reimbursed.

Widow sues for the costs of the treatment of her deceased husband. But now the Federal Social Court has ruled in a current judgment contrary to common practice. In this case, a macular degeneration patient who had since died had requested reimbursement from his health insurance fund for three Lucentis injections in the amount of € 1,523.96 per injection. However, the fund approved only part of the costs, on the grounds that it was possible "to divide the single-use syringe into two or three patient-friendly dosage forms," ​​the court said. However, since the insured claimed to receive the medication in compliance with the approval, only private treatment was possible, resulting in a total cost of 5,769.78 euros. The husband's widow and sole heiress sued and won because the social court decided in accordance with section 13 (3) sentence 1, case 2, that the health insurance fund should cover the full costs of the treatment.

Patients have the right to approval-compliant administration. According to this, insured persons, because of possible risks, would not have to agree against their will to divide the single-use syringe into two or three doses. In addition, the health insurance fund could not rely on the fact that the treatment was formally but not materially in accordance with the fee schedule for doctors. The reason: The defendant health insurer had not offered the insured to support him in a legal dispute against the doctor treating him and to waive the costs. (No)

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