Reimbursement of Treatment Costs by Health Insurance Funds against a Physician

Facts

The case concerns a dispute between a physician (Dr. G.) and several health insurance funds regarding the reimbursement of treatment costs. The Cantonal Association of Lucerne Health Insurance Funds had objected that the physician's invoices for the year 1968 were too high and demanded a 40% reduction. For the invoices from May 1, 1969 onwards, the Association demanded a 25% reduction. The arbitration tribunal of the Canton of Lucerne partially upheld the health insurance funds and obliged the physician to reimburse 25% of the invoices submitted in 1968 and 1969. The physician filed an administrative court appeal against this decision.

Considerations

1. The Federal Insurance Court first establishes that the arbitration tribunal of the Canton of Lucerne is considered a lower court within the meaning of Art. 105 para. 2 of the Federal Act on the Organization of Federal Judicial Authorities (OG). Therefore, the Federal Insurance Court is bound by the findings of fact of the arbitration tribunal, unless they are obviously incorrect, incomplete or made in violation of essential procedural provisions. 2. The Federal Insurance Court concludes that the arbitration tribunal wrongly entered into the claims of the Cantonal Association regarding the invoices from May 1, 1969 onwards. According to Art. 25 para. 4 of the Federal Act on Sickness and Accident Insurance (KUVG), a mediation or conciliation procedure must precede the arbitration procedure. Since such a procedure was not carried out for the invoices from May 1, 1969 onwards, the arbitration tribunal was not allowed to decide on them. 3. With regard to the invoices from the year 1968, the Federal Insurance Court confirms the case law that Art. 23 KUVG grants the health insurance funds a right of reimbursement against physicians who have not complied with the principle of economic treatment. 4. The Federal Insurance Court explains that the health insurance funds' right of reimbursement under Art. 47 para. 2 AHVG expires after one year from the time the fund became aware of it, but at the latest after 5 years from the submission of the invoice. Therefore, the contractual deadline of 6 months…