Insurer's Right to Demand Reimbursement of Overpayment from a Healthcare Provider in the Third-Party Payer System

Facts

On 16 July 1998, thirty-two health insurers represented by the Vaud Federation of Health Insurers (FVAM) requested the Vaud Cantonal Insurance Arbitration Tribunal to order the reimbursement of a sum of 122,000 francs with 5% annual interest from 1 July 1996, which they considered to have been unduly paid to Dr. P., a physician. The arbitration tribunal declared the claim inadmissible, which the health insurers contested before the SCC.

Considerations

The SCC ruled that the health insurers have an inherent right, under Art. 56 para. 2 let. a HIA, to demand reimbursement from the healthcare provider of sums that were unduly received, even in the third-party payer system where the insured person directly remunerated the physician. This case law, established under the former law (LAMA), has been carried over into the HIA.

According to the SCC, the fact that the insured person is the debtor of the physician's remuneration does not deprive the insurer of its right to take action for reimbursement against the latter. This right of the insurer stems from a…