Facts
The appellant [A.] , born in 1953, is insured with Helsana Insurances AG in the voluntary daily allowance insurance under the HIA for a daily allowance of CHF 120 per day with a waiting period of 14 days. On 25 October 2004, he reported himself as incapable of work since 19 May 1999 due to illness and accident. On 23 February 2005, Helsana decided that the entitlement to daily allowance benefits only exists to the extent that the insured person does not derive any insurance gain. Since [A.] could not provide proof of uncompensated loss of earnings at the beginning of his illness, only a daily allowance of a maximum of CHF 10 was paid. [A.] appealed against this decision, which was dismissed by the Insurance Court of the Canton of Solothurn on 23 April 2007. [A.] then filed a public law appeal to the DFC.Considerations
The DFC notes that the voluntary daily allowance insurance under Art. 67 et seq. HIA is a pure loss of earnings insurance. According to the case law, an unemployed person who is not entitled to daily allowances from the unemployment insurance can also suffer a loss of earnings that entitles them to sickness allowances. However, the prerequisite is that it is established with a high degree of probability that the insured person would have been employed if they had not been ill.
In the present case, the DFC assumes that the appellant belongs to the category of cases in which the insured person becomes ill after having already become unemployed. In such cases, the presumption applies that the insured person would not have been employed even if they had not become ill. However, this presumption can…