Refusal to cover the costs of stay in a medical-social institution beyond the daily flat rate of 60 francs

Facts

Mrs. [B.], born in 1919, was insured with the Swiss Health Insurance Fund for the wood and construction industries and related branches (CMBB) for compulsory health care insurance. She has been staying in a medical-social institution since December 1991. On June 2, 1997, she requested the payment of the benefits for hospitalized patients provided for by the Federal Health Insurance Act (HIA) from January 1, 1997 onwards. The insurance fund refused, stating that the costs of stay in a medical-social institution were only covered up to a daily flat rate of 60 francs. After having brought the case before the Insurance Court of the Canton of Vaud, Mrs. B.'s appeal was dismissed. Her husband, [B.], then filed an administrative law appeal against this judgment.

Considerations

The Federal Insurance Court dismissed the appeal. It considered that Art. 49 para. 3 HIA, which provides for the applicable tariff in case of hospitalization, is only applicable when the patient, according to medical indication, requires treatment and care or medical rehabilitation in a hospital setting. However, in the present case, it was not alleged that the care provided to Mrs. [B.] in the medical-social institution did not correspond to her actual needs. Consequently, the benefits provided for in Art. 50 HIA for the stay in a medical-social institution applied, and not those of Art. 49 para. 3 HIA relating to hospitalization.

The…