Facts
Insured person L., residing in the canton of Basel-Stadt, was admitted for inpatient treatment at Clinic B. located in the canton of Basel-Landschaft. The health insurance company Assura initially refused to cover any costs beyond the amount of CHF 1,900.-, as the insured person had reached a settlement agreement with the responsible liability insurer. However, the cantonal insurance court upheld the insured person's appeal and ordered Assura to pay the remaining amount of CHF 4,543.40. Assura subsequently filed an administrative court appeal. The Federal Supreme Court had to determine the applicable tariff for the cost coverage, as Clinic B. was listed on the hospital lists of both the canton of residence and the canton of location.Considerations
The Federal Supreme Court stated that the reasons for medical necessity as a requirement for the admission of a service provider (Art. 39 para. 1 lit. d and e KVG) and as a prerequisite for the extension of full tariff protection beyond the borders of the canton of residence (Art. 41 para. 2 KVG) are not identical. While the inclusion of a hospital in a hospital list means that it is an approved service provider, this does not yet determine the applicable tariff. According to Art. 41 para. 1 sentence 3 KVG, the tariff of the insured person's canton of residence is decisive, even if they choose an out-of-canton service provider that is listed on the hospital list of the canton of residence. Only if there are…