Decision of the Federal Court on the Canton's Cost Contribution for Inpatient Treatment of an IV Patient

Facts

The Federal Court had to assess whether the Canton of Zurich is obliged, pursuant to Art. 14bis IVA in conjunction with Art. 39 HIA, to contribute 20% to the costs of inpatient orthodontic treatment of an IV patient in a clinic that is not listed on the hospital list of the Canton of Zurich and does not have a service mandate for this area. The case concerns an insured person born in 1997 who was treated for a malocclusion. The treatment took place from April 21 to 24, 2016 at Clinic D. of A. AG. The clinic invoiced the Disability Insurance for CHF 17,494.15 and demanded a cost contribution of CHF 4,373.55 from the Canton of Zurich. However, the Canton of Zurich denied the cost obligation, as Clinic D. is not listed on the hospital list of the Canton of Zurich. The Social Insurance Court of the Canton of Zurich obliged the Canton to pay the amount of CHF 4,373.55. The Canton appealed against this decision to the Federal Court.

Considerations

The Federal Court concluded that the reference in Art. 14bis IVA to Art. 39 HIA not only includes the formal requirement of a "listed hospital", but also the aspect of the specific service mandate. Accordingly, the reimbursement of costs by the Canton requires that the hospital where the treatment took place has a service…