Review of the medical justification for a hospital stay by the health insurer

Facts

The case opposes a service provider (the X Hospital Association) to a health insurer (Visana) concerning the latter's right to make the coverage of hospitalization costs for a period exceeding 30 days subject to the provider's medical justification of the extension of the hospitalization. The three patients insured with Visana were hospitalized at the G. Hospital managed by the X Hospital Association. For each of them, Visana issued a payment guarantee limited to 30 days, with the possibility of extension based on a medical report. The hospital refused to provide these reports, considering that the systematic limitation of the guarantee period called into question the economic nature of the treatment. Visana therefore only covered the first 30 days of hospitalization. The X Hospital Association then brought the case before the Cantonal Arbitration Tribunal to obtain payment of the remaining costs.

Considerations

The Federal Tribunal considers that health insurers not only have the right, but also the obligation to exercise, with the assistance of their medical advisor, close monitoring of hospital treatment in order to verify its economic nature, in accordance with Art. 32(1), 39(1), 49(3) and 57 HIA. A limitation of the duration of the payment guarantee, which can then be extended based on medical information, is an adequate means of ensuring the medical justification of a relatively long hospital stay. However, this control must respect certain principles: it must…