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The cash register does not have to pay: no fictional approval for liposuction
If a health insurer does not process an insured person's application in good time, it is actually considered approved. However, this legal regulation must not lead to abuse of rights, judged a court. The verdict was due because a woman wanted liposuction.
New legal regulations must not lead to abuse of rights
If a health insurance company does not process an application in good time, it is considered approved. However, this new legal regulation must not lead to abuse of rights, the State Social Court (LSG) Lower Saxony-Bremen has now ruled in a judgment published on Monday. In the negotiated case, Techniker Krankenasse (TK) had informed a 53-year-old woman from Osterholz (Lower Saxony) that she was not paying for liposuction, as this was not an approved treatment method.
Fat deposits in the arms and legs
As the court wrote in a statement, the woman had suffered from increased fat deposits in her arms and legs for many years; at a size of 1.68 meters, it weighed 87.5 kilos.
After the health insurance company had informed in an ongoing opposition procedure that liposuction (liposuction) was not an approved treatment method and was therefore not being paid for, the woman made a second application.
But this time during a vacation trip on the island of Jersey / Great Britain at the German Honorary Consulate for forwarding to the cash register.
A few weeks later, she made an urgent request to the court. Because of the "frightening development" of the disease, liposuction must now be done very quickly.
On her second application, she received no feedback within the processing period, so that, in her opinion, the fiction of approval had occurred.
Requirements for an express procedure
However, the LSG could not agree with the legal opinion of the applicant.
As stated in the communication, the prerequisites for an urgent procedure are serious and unreasonable disadvantages, which cannot be avoided in any other way and which could not be eliminated by waiting for the decision in the main.
Increased perceived complaints in the legs after a flight to a holiday island would not meet these requirements. In addition, the approval fiction did not occur legally.
The endeavor to seek fiction of approval by submitting an alleged application to a German consulate abroad borders on abuse of rights.
In principle, an application can also be submitted through a consulate. However, the deadlines for the fictional approval according to their meaning and purpose could not apply from the submission of the application. (ad)