Facts
The insured person [E.] , born in 1925, is insured with the KPT health insurance company. She suffers from moderate dementia, high blood pressure, venous insufficiency, and other health problems. For years, she has been receiving home care services from Spitex. Initially, KPT only covered a portion of the requested care hours, prompting [E.] to file a complaint. The Administrative Court of the Canton of Bern ordered KPT to cover the costs for 123.55 hours of care services per quarter. KPT then appealed to the Federal Supreme Court.Considerations
The Federal Supreme Court partially upheld the appeal. It determined that the insured person is entitled to reimbursement for 86.7 hours of care services per quarter. The Federal Supreme Court considered that health insurance generally covers the costs of examinations, treatments, and care measures provided by persons acting on the orders or on behalf of a physician. In assessing the specific care needs, the responsible persons have a certain degree of discretion, which should only be intervened in with restraint, especially when it concerns the insured person's general practitioner. The Federal Supreme Court partially corrected the lower court's decision. The weekly measurements of blood pressure,…