Facts
The late P. was insured with CSS Assurance, in particular for compulsory nursing care. She stayed in the nursing care service of the X retirement home from 16 December 1996 due to her care needs. CSS Assurance covered a daily contribution of 40 francs from 1 January 1997. The insured's husband, [D.], requested reimbursement of the costs of 61,794.30 francs for the services billed by the medical-social institution from 1 January to 31 July 1997. CSS Assurance maintained that it should only cover the daily tariff flat rate of 40 francs as well as medical services, therapies and medicines according to the tariff. Following a partial objection, CSS Assurance set the daily flat rate to be reimbursed at 70 francs, after the Federal Council had essentially confirmed the tariff decided by the Cantonal Council of Zurich for 1997 in the absence of an agreement. [D.] then filed an administrative law appeal to obtain full reimbursement of the care costs.Considerations
According to case law, the contracting parties have a wide margin of discretion in setting tariffs, with the court intervening only in a very reserved manner, unless the application of a tariff position leads to a manifestly illegal disadvantage or advantage of one party, or if the tariff is not based on objective considerations.
The tariff set by the Cantonal Council on 2 October 1996 for the period without an agreement from 1 January 1997 has the character of a transitional solution, given that the decisive bases for setting the tariffs according to Art. 50 in conjunction with Art. 49 para. 6 HIA, namely the cost accounting and service statistics of the service providers, were not yet available. In setting this tariff, the Cantonal Council took into account the fact that the actual costs of care…