Facts
The Association of Grisons Hospitals (VBK) and the Cantonal Association of Grisons Health Insurers (KBK) concluded a contract on June 17/July 7, 1997 regarding the benefits for inpatient treatment in nursing homes and nursing departments (nursing home contract). Differences of opinion arose between the contracting parties regarding the crediting of helplessness allowances from the Old Age and Survivors' Insurance/Disability Insurance (AHV/IV) against the nursing care benefits of the health insurers. The VBK filed a lawsuit with the arbitration tribunal to determine that no helplessness allowances may be deducted from the nursing care lump sums.
The Arbitration Tribunal of Graubünden upheld the VBK's claim. The KBK then filed an administrative court appeal with the Federal Insurance Court.
Considerations
The Federal Insurance Court concluded that the health insurers affiliated with the nursing home contract are not entitled to reduce the agreed nursing care lump sums to the extent of the helplessness allowances paid by the AHV or IV.
Neither the nursing home contract nor the Health Insurance Act provide for a regulation whereby helplessness allowances from the AHV/IV and nursing care benefits from health insurance under Art. 7 para. 2 KLV cannot generally be cumulated. A reduction of nursing care benefits due to over-compensation is possible under Art. 122 KVV if the benefits are of the same type and purpose. However, the helplessness allowances and the nursing care benefits under Art. 7 para. 2 KLV differ in…