Rejection of Cost Coverage by the Supplementary Insurance for Inpatient Treatment in a Clinic without a Tariff Agreement

Facts

The plaintiff [X.] , born in 1982, suffers from a mental illness and has been insured with the defendant [Y. AG] since 1982. Until the end of 1996, she was insured under the HIA supplementary insurance "Combined Hospital Insurance". With the introduction of the HIA and the subordination of the supplementary insurances under the IPA, the transfer to the [Y.] -Standard Insurance took place on January 1, 1997. In April 2005, the [Z.] Women's Clinic requested cost coverage from [Y.] for the inpatient treatment of [X.] . [Y.] rejected this with reference to the lack of a contract, but covered the costs for a maximum of 60 days in the general ward of the responsible public hospital. [X.] then stayed in the private ward of the [Z.] Clinic from June 16 to June 16, 2005 and from June 19 to June 30, 2005. [X.] subsequently filed a lawsuit against [Y.] for the issuance of cost coverage or reimbursement of the costs for the stay in the [Z.] Clinic. The Insurance Court dismissed the claim.

Considerations

The DFC upheld the decision of the lower instance: - The guarantee of existence according to Art. 102 para. 2 HIA only applies to benefits that go beyond the scope of benefits of the basic insurance. It does not oblige the insurer to conclude a supplementary insurance with comprehensive freedom of choice of hospitals. - The scope of benefits of the supplementary insurance is determined according to Art. 13.1 lit. l of the General Insurance Conditions (AVB). According to this, only costs for hospitals with which [Y.] has…