Obligation of the Supplementary Insurance to Provide Benefits in the Absence of a Tariff Agreement between the Insurer and the Service Provider

Facts

A., a woman who has been insured with the CSS Insurance for many years, was insured in the KUVG supplementary insurance "Combined Hospital Insurance" with benefit group 2: semi-private ward until the end of 1996. With the introduction of the KVG and the subordination of the supplementary insurances under the VVG, this insurance was transferred to the "Semi-private Hospital Insurance, Healing Cost Insurance" at the CSS on January 1, 1997. In October 2004, A. concluded a new (modified) health insurance contract "Semi-private Hospital Insurance, Healing Cost Insurance" which became effective on January 1, 2005.

In April 2005, the Meissenberg Women's Clinic, where A. wanted to receive inpatient treatment, requested cost approval from the CSS. However, the CSS refused this, as the clinic was on the "List of Hospitals without General and/or Semi-private Wards" because there was no tariff agreement for the general and semi-private wards. A. then filed a lawsuit with the District Court of Lucerne-City and demanded the difference between 75% of the total invoice amount for the hospital stay and the OKP flat rate guaranteed by the CSS.

Considerations

The Federal Court states that according to the General Insurance Conditions (AVB) of the "Semi-private Hospital Insurance", insurance benefits are only provided for hospitals with which the CSS has concluded a tariff agreement. Since this has not been the case for the Meissenberg Women's Clinic since the beginning of…