26 November 2024 – In its decision of 15 February 2024, the Federal Supreme Court partially upheld the appeal of a patient insured with Helsana Versicherungen AG. The appellant sought reimbursement for the costs of a H.E.L.P.- apheresis treatment to address the effects of his post Covid-19 condition.

The dispute originated from the appellant’s application for coverage of the H.E.L.P.- apheresis treatment costs under his mandatory health insurance (obligatorische Krankenpflegeversicherung, OKP). Helsana denied the request and upheld its decision after consulting its trusted medical service. Subsequently, the appellant appealed to the Insurance Court (Versicherungsgericht) of the Canton of Aargau.

The court reviewed whether the cantonal court had violated federal law by denying Helsana’s obligation to cover the treatment costs for the H.E.L.P.- apheresis. The central question concerned the legal requirements of the Health Insurance Act (Bundesgesetz über die Krankenversicherung, KVG) for the reimbursement of treatment costs by the OKP, particularly the application of the criteria of efficacy, appropriateness and cost-effectiveness (Kriterien der Wirksamkeit, Zweckmässigkeit und Wirtschaftlichkeit, WZW criteria). According to federal law, treatments must be scientifically proven to be effective in order to qualify to be reimbursed.

The court noted that the cantonal court had concluded that there were no studies proving the efficacy of H.E.L.P.- apheresis in the treatment of post Covid-19 conditions and that there were only theoretical indications of its efficacy. While acknowledging this point, the court emphasized that the cantonal court had overlooked the statutory presumption of efficacy under the KVG for treatments prescribed by a physician, unless they are expressly excluded by the Federal Council’s list. The court ruled that mere doubts about the efficacy of a treatment are not sufficient grounds to refuse coverage. Instead, in the absence of conclusive evidence, the treatment is legally presumed to be effective unless proven otherwise.

Additionally, the court found that the cantonal court had failed to obtain an independent expert opinion to assess the treatment's efficacy. As a result, the case was referred to Helsana for further investigation to ensure that the legal criteria are fully met, and that the treatment’s efficacy is rigorously assessed.

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