Federal Supreme Court, Decision 9C_246/2020 of 4 March 2021

28 marzo 2021 – In this decision, the Federal Supreme Court had to decide whether the health insurance company (respondent) of the appellant must cover the costs of an abdominoplasty. After a bariatric surgical intervention (creation of a proximal gastric bypass), the appellant was able to reduce her body weight from 109.8 kg to 66 kg at a height of 175 cm. The abdominoplasty was subsequently intended to remove the fat tissue.

In connection with the abdominal fat tissue, the lower court stated that based on the present conditions documented by photographs, when viewed objectively and in accordance with the apparently perceptible features, it was not possible to speak of a conspicuously disfigured part of the body. The appellant, on the other hand, argued that her situation was comparable to breast reconstruction after breast cancer surgery and that she was therefore entitled to equal treatment and assumption of the costs.

The Federal Supreme Court did not follow this line of argument. However, with regard to the question of whether the aesthetic defect led to pathological sequelae, the treatment of which - if the requirements were met - would be borne by the respondent, the Federal Supreme Court held that none of the medical opinions on record could form the basis for an assessment that was sufficient in terms of evidence, in particular comprehensive and comprehensible with regard to the medical correlations. In this legal situation, the lower court should not have waived further medical clarifications in an anticipatory assessment of the evidence. The appeal was therefore partially upheld and referred back to the lower court for a new decision.

For the full decision, see here.