Facts
Insured person X had been employed at company A since April 6, 1993. There was a collective agreement for sickness benefit insurance between this company and health insurance fund Y. On May 19, 1993, X submitted the entry form to the health insurance fund and stated that he was a diabetic. In the insurance application dated June 4, 1993, the questions about the state of health were no longer answered, but reference was made to the entry notification. Admission to the insurance was made with a reservation for diabetes.
On July 26, 1994, the fund's medical officer reported that the insured person's medical treatments had actually focused primarily on an infection and less on diabetes in recent times. On July 27, 1994, the health insurance fund informed X that there was a suspicion of HIV seropositivity. X confirmed his HIV seropositivity and admitted that he had known about this infection since 1986.
By decision of September 14, 1994, the fund retroactively excluded X from the sickness benefit insurance. The reasons given were incomplete information about the state of health in the insurance application and a breach of the duty to cooperate.
Considerations
The Federal Court confirmed its previous case law, according to which the HIV infection has the character of an illness in the legal sense. The following aspects were particularly decisive:
The HIV infection requires treatment immediately after infection and gives rise to benefits from health insurance funds. Although the infection is initially asymptomatic in the majority of cases, there is nevertheless a treatable illness at this stage. Also with regard to existing and future treatment options, it is justified to consider the HIV infection…