4 December 2024 – In its decision of 18 November 2024, the Federal Supreme Court dismissed the appeal filed by A. against the decisions of the Cantonal Court of Wallis and the health insurance company B., which had denied reimbursement for the costs of a «metal-on-metal hip resurfacing» (Hüft Resurfacing Arthoplastik, HRA) procedure performed in the United Kingdom.

The dispute revolved around whether the appellant was entitled to have the costs of an overseas hip resurfacing operation covered by his compulsory health insurance (obligatorische Krankenpflegeversicherung, OKP). The insurance company had rejected the request, arguing that the procedure was not medically necessary, as suitable alternatives were available in Switzerland, namely the hip total endoprosthesis (Hüfttotalendoprothese, HTEP). The appellant contended that the HRA was a more suitable treatment option for him and should be reimbursed.

The court examined whether the cantonal court had violated federal law in its decision. It affirmed that the Swiss health insurance system generally follows the principle of territoriality, meaning that medical treatment performed abroad is only covered in emergencies or when no equivalent treatment is available in Switzerland. However, under the heading of lack of treatment services (art. 36 para. 1 Ordinance on Health Insurance [Verordnung über die Krankenversicherung, KVV]), only serious «treatment gaps» justify an exception to the territoriality principle. In this case, the court found that the HTEP, an established and recognized treatment in Switzerland, provided an equally effective and appropriate alternative to the HRA.

The court further emphasized that while the HRA might offer certain personal benefits to the appellant, these were not sufficient to justify the need for treatment abroad, particularly given the significant risks associated with the metal-on-metal HRA. The court also noted that the newer ceramic HRA technique was still experimental at the time of the request and had not been approved for reimbursement.

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