Facts
B., born in 1932, underwent bilateral breast reduction surgery on September 13, 1999. Her health insurance, Helsana Versicherungen AG, initially refused to cover the costs of the procedure. However, the Administrative Court of the Canton of Lucerne ordered Helsana to cover the costs of the breast reduction surgery. Helsana then filed an administrative court appeal with the aim of overturning the cantonal decision.
Considerations
The Federal Supreme Court examined whether the breast reduction surgery constituted an effective and appropriate service within the meaning of Art. 32 para. 1 KVG and was therefore to be covered by the mandatory health insurance.
The Federal Supreme Court found that the requirements for coverage of the breast reduction surgery were generally met, as the patient had lost more than 500 g of weight per breast and did not suffer from obesity. However, it was disputed whether the claimed complaints (neck and shoulder pain, shortness of breath, feelings of oppression and sensations) were predominantly likely to be attributable to the hypertrophy of the breasts.
The Federal Supreme Court pointed out that in addition to breast hypertrophy, other factors such as weak back and abdominal muscles, postural abnormalities, and degenerative changes in the spine could have contributed to the complaints.…