Reimbursement of Dental Treatment Costs under Supplementary Benefits

Facts

Mr. [M.], a recipient of supplementary benefits (PC) to the old-age pension, underwent dental treatment between November 1999 and January 2000. The total costs amounted to CHF 7,775.15, of which CHF 200 were covered by the SWICA supplementary insurance. Mr. [M.] requested reimbursement of the remaining CHF 7,575.15 from the PC. The PC compensation institution of the canton of St. Gallen only granted him CHF 3,000, on the grounds that no cost estimate had been approved in advance.

Mr. [M.] appealed against this decision. The Insurance Court of the canton of St. Gallen partially upheld his appeal and referred the matter back to the PC compensation institution for a new decision. The Federal Social Insurance Office then appealed against this cantonal decision.

Considerations

The DFC considers that Art. 8 para. 3, 2nd sentence, of the OPFPC cannot be interpreted in a way that simply limits reimbursement to CHF 3,000 when no cost estimate has been submitted to the competent institution in advance. If the PC recipient can prove that the treatment was simple, economical and appropriate, the full costs must be covered within the available amount.

Thus, when dental treatment has been carried out without a previously approved cost…