Coverage by the mandatory health insurance of services provided by salaried physicians of an outpatient care institution

Facts

The dispute concerns the coverage by the health insurance fund Assura of services provided in 2004 to two of its insured persons by salaried physicians of the company SOS Médecins Cité Calvin SA, an outpatient care institution within the meaning of Art. 35 para. 2 let. n HIA. Although these physicians did not have an authorization to practice at the expense of the mandatory health insurance on an individual basis, the Federal Tribunal ruled that the outpatient care institution was not subject to the limitation on the admission of service providers provided for in Art. 55a HIA and that, consequently, the services provided by its salaried physicians had to be covered by the mandatory health insurance.

Considerations

The Federal Tribunal first noted that Art. 55a HIA and the related ordinance only apply to service providers within the meaning of Art. 36 to 38 HIA, namely physicians, pharmacists and other providers listed in Art. 35 para. 2 let. c to g and m HIA. On the other hand, outpatient care institutions within the meaning of Art. 35 para. 2 let. n HIA, which employ salaried physicians, are not subject to this limitation on admission.

Furthermore, the Federal Tribunal considered that salaried physicians working for an outpatient care institution do not need to have an authorization to practice at the expense of the mandatory health insurance on an individual basis either. Indeed,…