Coverage of medical treatment costs for an insured person by the mandatory health insurance

Facts

[A.], born in 1943, was insured with Vivao Sympany AG. On December 8, 2014, he was admitted to Hospital [B.] for a knee operation. A few days later, he suffered a heart attack and kidney failure, which led to further complications and treatments. In total, [A.] spent 421 days in Hospital [B.] before being transferred to Hospital C. for rehabilitation. Hospital [B.] issued an invoice for the treatment of [A.] totaling CHF 2,410,744.45, of which it claimed CHF 1,325,909.30 from the canton of residence and CHF 1,084,835.10 from Vivao Sympany AG.

Vivao Sympany AG paid only CHF 300,000 and refused to cover the remaining amount of CHF 784,835.10, arguing that the costs were disproportionately high. Hospital [B.] then sued for the payment of the remaining amount.

Considerations

The Federal Supreme Court dismissed the appeal of Vivao Sympany AG and confirmed that the mandatory health insurance must fully cover the costs of A.'s treatment at Hospital B.

The Federal Supreme Court stated that according to the Health Insurance Act (KVG), the services must be effective, appropriate, and economical. These criteria must be cumulatively fulfilled to ensure efficient and high-quality healthcare at the most favorable costs.

In the…