No Reimbursement of Home Care Services by the Health Insurer to the Insured's Husband who is not Approved as a Service Provider

Facts

W., born in 1947, is mandatorily insured for nursing care with Helsana Versicherungen AG and has been receiving home care services for some time due to the consequences of poliomyelitis. In July 1997 and again in March 1999, the insured person requested reimbursement of the home care services to her husband, who had taken early retirement. Helsana rejected this on the grounds that it is not possible under the legal regulations to provide home care services to private individuals.

The Administrative Court of the Canton of Thurgau obliged Helsana in its decision of 15 December 1999 to provide the insured person with the statutory and regulatory benefits for the nursing services provided by the husband within the framework of the needs assessment. Thereupon, Helsana filed an administrative court appeal with the aim of confirming the objection decision of 11 August 1999.

Considerations

The Federal Court concluded that the power of substitution, which is recognized in the case law for disability insurance, is not applicable in the present case of compulsory health insurance. The power of substitution requires that two different but functionally interchangeable insurance benefits are at issue. In the present case, however, it is not a matter of exchanging benefit claims, but of exchanging service providers (approved and non-approved).

According to the…