Facts
The opposing party W., born in 1948, is insured with Helsana Versicherungen AG under the Federal Health Insurance Act (KVG) and, according to the medical diagnosis, suffers from paranoid schizophrenia. She has been cared for by the certified psychiatric nurse R. since 1999, for which Helsana provided benefits from the mandatory health insurance. After receiving a new medical prescription for the period from April 1 to June 30, 2002, Helsana reviewed the obligation to provide benefits for the planned measures and ultimately rejected them.
W. filed a complaint with the Administrative Court of the Canton of Thurgau and requested that Helsana be obligated to reimburse the services provided by R. The cantonal court partially upheld the complaint, whereupon Helsana filed an administrative court appeal with the Federal Supreme Court.
Considerations
The Federal Supreme Court states that persons with mental illness are generally entitled to benefits for outpatient nursing care in the same way as persons with a physical health impairment, in accordance with Art. 7 of the Ordinance of the Federal Department of Home Affairs on Benefits in the Mandatory Health Insurance (KLV). The obligation to provide benefits requires that there is a mental health condition in need of treatment and that the person is under medical treatment.
Measures for assessment and counseling according to Art. 7 para. 2 lit. a KLV are permissible for persons with mental illness, provided they are oriented towards nursing care and do not have a therapeutic character. Nursing care measures according to Art. 7 para. 2 lit. b…