Facts
M., born in 1974, had to undergo a surgical procedure by Dr. med. S. at Hospital X on January 28, 1997, as she suffered from pericoronal infections and cysts due to impacted wisdom teeth. M. submitted the total costs of CHF 3,259.15 for this procedure to her health insurance company Hermes. The health insurance company only covered the regulatory maximum amount of 150 Swiss francs from the supplementary insurance for medical expenses and rejected any obligation to pay under the mandatory health insurance.
M. filed an objection against the decision of the health insurance company and requested that it be obliged to cover the costs of CHF 3,158.95 in connection with the procedure on January 28, 1997. The Administrative Court of the Canton of Bern dismissed the appeal, whereupon M. filed an administrative court appeal with the Federal Supreme Court.
Considerations
The Federal Supreme Court states that the services of dentists in the mandatory health insurance are only covered to a limited extent, namely when the dental treatment is necessitated by a severe, unavoidable disease of the masticatory system. The provisions of Art. 17 of the Ordinance on Benefits in the Mandatory Health Insurance (KLV) specify which diseases of the masticatory system are considered severe.
The Federal Supreme Court considers that the disease value according to Art. 17 KLV represents a qualified concept, which is higher than the general concept of illness under Art. 2 para. 1 KVG. Not every impairment of health due to…