Reimbursement of Unlawfully Paid Benefits by an Insured Person

Facts

In this case, it was about the reclaiming of health insurance benefits that had been unlawfully paid to an insured person. The insured person, G., had received benefits from the Visana health insurance fund, which the fund later wanted to reclaim.

The Federal Supreme Court had to decide whether the fund could reclaim the benefits in accordance with Art. 47 AHVG, even though the Health Insurance Act (KVG) does not contain any specific provisions for reclaiming benefits.

Considerations

The Federal Supreme Court concluded that Art. 47 AHVG can be applied analogously to the reclaiming of unlawfully paid benefits by the health insurance, since the KVG does not contain its own regulations on this matter.

However, for a reclaiming under Art. 47 AHVG, the requirements for a review or revision of the benefit decision must be met. This means that the original benefit approval must either be obviously incorrect or that new facts or evidence must be available that could lead to a different legal…