Facts
Sisters E.F. and H.F. were admitted to Hospital B. on an emergency basis on June 21, 1996 due to a deterioration of their health condition, which was attributable to insufficient food and fluid intake. The health insurance company Konkordia initially covered the costs of the hospital stay according to the tariff for acute hospital treatment, but from June 28, 1996 onwards, only granted reimbursements at the rates for nursing care services.
The Insured Persons' Advisory Board filed a complaint against this decision and requested that Konkordia be obligated to cover the costs for acute hospital treatment until September 6, 1996. The Insurance Court of the Canton of Aargau dismissed the complaint, whereupon the Advisory Board filed an administrative court appeal.
Considerations
Pursuant to Article 49 paragraph 3 of the Health Insurance Act (KVG), reimbursement for hospital stays is based on the hospital tariff as long as the patient requires medical treatment and care or medical rehabilitation in the hospital according to medical indication. If this requirement is no longer met, the tariff for the nursing home under Article 50 KVG applies.
The principle of Article 49 paragraph 3 KVG corresponds to the previous case law on the principle of economic efficiency. Accordingly, the insured person must choose the medical institution or hospital department to which they belong from a medical perspective. The health insurance company does not have to cover any additional costs resulting from the insured person going to a specialized and therefore expensive clinic for intensive care and treatment, if they do not require such treatment.
In the present case, the nutritional and fluid deficit that was the reason for the emergency hospitalization could be remedied relatively quickly. The subsequent rehabilitation measures such as physiotherapy and gait exercises could have been…