BGE 145 V 116 (Federal Supreme Court, Decision 9C_744/2018 of 1 April 2019)

30 luglio 2019 – The Federal Supreme Court rejected an appeal of a health insurance company, which argued that, according to case law of the Court, there is a limit to cover costs of hospital treatment by the mandatory health insurance and that this limit is determined on the basis of the "QALY method". The health insurance company argued that, according to this method, in the specific case of a 71-year-old man, who suffered a heart attack, kidney failure and numerous other, sometimes life-threatening complications after knee surgery and who was therefore treated in hospital for 421 days, it was not obliged to cover the full costs of the patient's treatment. Due to the life expectancy and the low quality of life of the patient, the health insurance company assumed that it only had to cover an amount of CHF 300'000 instead of CHF 1.08 million.

The Federal Supreme Court decided that there is no absolute limit on the costs to be covered by mandatory health insurance. According to the Health Insurance Act (SR 832.10; Bundesgesetz über die Krankenversicherung, KVG), there is an unlimited obligation to cover the costs of hospital treatment as long as each individual measure or treatment fulfils the requirements of effectiveness, usefulness and economic efficiency. The court pointed out that one of the objectives of the Health Insurance Act was precisely to ensure that health insurance companies are obliged to cover the costs of stationary treatment for an unlimited period of time. Moreover, if the health insurance company had wanted to succeed with its claim of reduction of costs to be covered, it would have had to specify its doubts regarding the (economic) efficiency of the treatment of each illness and complication separately rather than to submit a general argument for all treatments.