Coverage for inpatient treatment in a psychiatric clinic

Facts

[A.] (the appellant) and the health insurance company [B.] (the respondent) had agreed on a supplementary insurance "[X.] " with the Gold benefit level, which covers the additional costs of the semi-private ward of a hospital in Switzerland. In 2017, [A.] requested cost coverage for a planned stay in the semi-private ward of a psychiatric clinic, which the respondent rejected. The Insurance Court of St. Gallen dismissed [A.] 's claim, as according to Clause 3.7 of the General Insurance Conditions (AVB), only the costs of the general ward for a maximum of 180 days within 1080 days are covered for inpatient treatment in a psychiatric clinic, regardless of the chosen benefit level.

Considerations

The Federal Supreme Court confirmed the decision of the Insurance Court. It stated that the interpretation of the AVB must be carried out according to the same principles as for other contractual provisions. The decisive factor is the consistent actual intention of the parties and, if this cannot be determined, the interpretation according to the principle of trust. Ambiguous clauses in the AVB must be interpreted against the insurer according to the rule of uncertainty, but this rule only applies if all other means of interpretation fail. The…