Coordination of benefits and overcompensation in compulsory health insurance

Facts

W. receives a severe disability allowance from the Old Age and Survivors' Insurance (AVS/AI) in addition to an old-age pension. She is also insured with ASSURA for medical care in case of illness and benefits from the coverage of home care costs. ASSURA notified W. that the disability allowance had to be deducted from the amount allocated for home care coverage. W. appealed this decision to the Administrative Court of the Canton of Neuchâtel, which annulled ASSURA's decision and referred the case back to ASSURA to establish a new calculation taking into account certain deductions. Both W. and ASSURA appealed this judgment to the Federal Supreme Court.

Considerations

The Federal Supreme Court considers that the disability allowance from the AVS/AI and the care benefits provided for in Art. 7 para. 2 OPAS are fundamentally different in nature. Although the basic care benefits listed in Art. 7 para. 2 let. c OPAS are essentially of the same nature as the disability allowance, the latter benefit is also intended to compensate for third-party services that are not included in the care benefits. Therefore, it is not justified to automatically deduct the full amount of the disability allowance from the benefits owed by the health insurer for care coverage. Only a reduction due to overcompensation should be taken into account.

The Federal Supreme Court considers that the amount of the deduction set by the…