Facts
F., born in 1949, suffers from congenital myatonia with tetraparesis and requires intensive care. She works part-time as an art therapist and lives in a 2-room apartment, where various persons selected by herself provide the necessary care services. Visana, with whom F. is mandatorily insured for nursing care, informed her that as of October 1, 1996, it will only reimburse an amount corresponding to the cantonal nursing home contribution of 40 Swiss francs per day for 1996 and 70 Swiss francs per day for 1997 and 1998.
F. filed a complaint against this decision, requesting that Visana be obliged to cover the costs for the necessary home care up to a maximum of five hours per day. The Social Insurance Court of the Canton of Zurich granted the complaint, whereupon Visana filed an administrative court appeal.
Considerations
The Federal Insurance Court states that under the Health Insurance Act (KVG), the mandatory health insurance covers the costs for examinations, treatments, and nursing measures provided on an outpatient basis, through home visits, inpatient, semi-inpatient, or in a nursing home. During a stay in a nursing home, the insurer reimburses the same services as for outpatient nursing care and nursing care at home.
The Court finds that the principle of economic efficiency in the service law of social health insurance has general significance and refers not only to the type and scope of the measures to be carried out, but also to the form of treatment. It must be examined whether a particular measure is to be carried out on an outpatient or inpatient basis and in which medical institution or department an insured person belongs. The question of the economic efficiency of treatment in relation between home care (home care services) and nursing home care may also arise.
The Court states that in assessing economic efficiency, the starting point should not be the total costs of a nursing home stay, but the costs that the health insurer is actually required to cover. However, the assessment must not be based…