Reclaiming Benefits Due to Inefficiency of Medical Treatment

Facts

The health insurers filed a request for conciliation proceedings with the Cantonal Parity Supervisory Commission of Graubünden against Dr. med. P. They demanded that Dr. med. P. reimburse the amount of CHF 41,052.50 for the year 2004. The KPVK obliged Dr. med. P. to reimburse the insurers the amount of CHF 30,789.40. Dr. med. P. appealed against this decision to the Federal Supreme Court.

Considerations

The Federal Supreme Court states that according to Art. 56 HIA, the service provider must limit his services to the extent that is in the interest of the insured and necessary for the purpose of the treatment. For services that exceed this measure, the reimbursement may be refused and an unjustly paid reimbursement may be reclaimed.

The Federal Supreme Court reviews its previous case law, according to which the incurred costs must also be included in the efficiency control. It concludes that according to the wording, the materials and the systematic of the law of Art. 56 para. 2 HIA, only the costs directly invoiced by the physician (including the medications he has dispensed) are subject to the…