Facts
On February 8/9, 2001, the Canton of Zurich, the Medical Society of the Canton of Zurich (AGZ), and Helsana Insurance AG concluded a framework agreement on the mandatory health insurance for asylum seekers, temporarily admitted persons, and persons in need of protection without a residence permit, who are fully or partially supported by the competent welfare authorities. This framework agreement provides for a restricted choice of service provider and cost reimbursement according to the third-party payer system.
Dr. med. M., who was not on the so-called asylum general practitioner list, treated the asylum seeker K., who was insured under the framework agreement from April 1 to August 31, 2001, during the period from July 25 to August 15, 2001. When Dr. med. M. demanded reimbursement of the services provided in an invoice dated October 4, 2001, Helsana refused to cover the costs.
Considerations
The Federal Supreme Court considers the restriction of the choice of service providers provided for in the framework agreement to be permissible. This restriction is based on Art. 41 para. 4 KVG and Art. 26 para. 4 AsylV 2.
The Federal Supreme Court states that welfare or social assistance does not have to guarantee the level of benefits that persons independent of welfare could afford from their own funds. The community responsible for welfare can…