Facts
I., born in 1995, traveled to Switzerland with his parents in September 1997, where they filed an asylum application. The pediatrician recognized that I. had a congenital heart defect that should be operated on as soon as possible. Concordia, the Swiss health and accident insurance with which the I. family was insured under the mandatory health insurance, refused to approve the costs due to a lack of statutory obligation to provide benefits. The Administrative Court of the Canton of Bern dismissed the appeal against this rejection.
I., legally represented by his father, then filed an administrative court appeal with the aim of obliging Concordia to cover the costs of treating his heart condition.
Considerations
The Federal Insurance Court states that the appellant's heart condition falls under item 313 of the Annex to the Congenital Defects Ordinance and that the obligation of the Disability Insurance to provide medical measures for this is only thwarted by the fact that the appellant does not meet the insurance clause pursuant to Art. 6 of the Federal Disability Insurance Act (IVG).
According to Art. 27 of the Federal Health Insurance Act (KVG), the mandatory health insurance covers the costs for the same benefits as in the case of illness for congenital defects that are not covered by the Disability Insurance. The wording of this provision as well as the French and Italian versions indicate that the obligation of the mandatory health insurance to provide benefits for a beneficiary under the age of twenty who suffers from a recognized congenital defect does not fail because he does not meet the…