Entitlement to Home Care Services Coverage by Health Insurance for Congenital Defects

Facts

- [V.] , born on 26 February 2007, is mandatorily health insured with the KLuG Health Insurance. - In August 2008, [V.] was diagnosed with a brain tumour (Congenital Defect No. 384). The IV-Stelle Schwyz (Disability Insurance Office Schwyz) granted cost approval for the treatment and awarded a helplessness allowance as well as an intensive care supplement. - The Kinderspitex Kanton Zürich (Paediatric Home Care Canton Zurich) submitted invoices for home care services from January to September 2009 to the KLuG, which were rejected by the KLuG. - [V.] filed a complaint against the rejection of the cost coverage by the KLuG. The Administrative Court dismissed the complaint.

Considerations

- Art. 27 HIA regulates the coordination between health and disability insurance for congenital defects. The health insurance covers the costs for services not covered by the disability insurance. - The Federal Supreme Court considers that the health insurance can remain subsidiarily liable for benefits, even if a congenital defect is covered by the disability insurance. Overcompensation is to be avoided. - The helplessness allowance and the intensive care supplement of the IV (DI)…