Refusal of coverage by the mandatory health insurance for a treatment abroad when appropriate treatment is available in Switzerland

Facts

[J.], a 53-year-old married man and father of three children, suffering from rectal adenocarcinoma, requested his health insurance, La Caisse Vaudoise, to cover the costs of a treatment at Clinic Y. in the United States, including intraoperative radiotherapy not available in Switzerland. The insurance company refused this coverage, a decision confirmed by the Cantonal Social Insurance Court of Geneva. [J.] then appealed this decision to the Federal Insurance Court.

Considerations

The Federal Insurance Court ruled that, although intraoperative radiotherapy could significantly reduce the risk of local tumor recurrence, this treatment could not be covered by the mandatory health insurance. Indeed, the standard treatment practiced in Switzerland, comprising preoperative radiotherapy followed by surgical intervention and chemotherapy, is considered appropriate and does not entail significantly higher risks for the patient compared to the alternative treatment abroad. The fact that the proposed…