Coverage of medical escort costs during patient transport

Facts

[S.], domiciled in T., is compulsorily insured with the Sanitas health insurance fund. On November 23, 2002, he was transported by ambulance with medical escort from his home to the Ospidal Val Müstair hospital, and then transferred around 24:00 with medical escort to the Oberengadin hospital. The invoices for these transports amounted to CHF 357.- and CHF 1'278.20, of which CHF 700.- were for the costs of the medical escort. After paying these invoices, [S.] requested Sanitas to reimburse them, but Sanitas only reimbursed the maximum amount of CHF 500.- provided for transport costs under Art. 26 HIBO. [S.] contested this decision.

Considerations

According to case law, the costs resulting from the necessary medical escort of a patient transport are not part of the transport costs, but constitute medical services within the meaning of Art. 25 para. 2 let. a HIA, the full coverage of which is the responsibility of the mandatory health insurance. Indeed, the legal distinction between transport services (Art. 25 para. 2 let. g HIA) and medical services (Art. 25 para. 2 let. a HIA) implies that the costs of the medical escort are not covered by the limited lump sum for transport costs.

However, when the transport is an integral part of inpatient treatment, the medical services provided during the transport are covered by the daily rate provided for in Art.…