Partial Grant of Appeal Against the Cancellation of the Legal Proposal by the Health Insurer Regarding Cost Sharing for Hospital Treatment

Facts

Parties and Procedural History:

The appellant ([A.] ) is compulsorily health insured with the respondent (Atupri Health Insurance). After hospital treatment, he was invoiced CHF 2,049.10 in cost sharing, which he did not pay. The health insurer then initiated debt enforcement proceedings. The appellant filed a legal proposal, which the respondent cancelled with a ruling dated 8 April 2021 and an appeal decision dated 3 September 2021. Against the ruling dated 8 April 2021, the appellant initially filed an appeal with the cantonal insurance court, which did not hear the case on grounds of jurisdiction and referred it to the respondent for handling as an appeal (Judgment VBE.2021.252 of the Insurance Court of the Canton of Aargau dated 7 June 2021).

Against the appeal decision dated 3 September 2021, the appellant filed a further appeal with the cantonal insurance court. The court partially granted the appeal and reduced the cost sharing by CHF 15 to CHF 2,034.10, as the discharge day was not included in the calculated hospital days. In all other respects, it dismissed the appeal (Judgment dated 20 May 2022).

Appellant’s Requests:

The appellant requested, on the merits, that the matter be referred back to the lower court to decide on his applications concerning the obligation to return the invoice to the hospital and review of the hospital invoice. He also requested the deletion of his entry in the debt enforcement register, the imposition of reminder, enforcement and file costs on the respondent, and compensation of CHF 100,000 for unnecessary proceedings and denied access to medical care. In procedural terms, he requested deletion from the list of defaulting insured persons, the release of procedural files, the imposition of procedural costs on the lower court, and compensation for drafting the appeal. Finally, he requested free legal aid.

Considerations

1. Procedural Applications and Release of Files:

The Federal Supreme Court did not entertain the appellant’s application to release various files of the respondent, as the grounds were insufficient (Art. 42 para. 1 and 2 FSCA; BGE 134 V 53 para. 3.3; 133 IV 286 para. 1.4). It was not apparent that the appellant had not received full access to the files in the previous proceedings. The appellant’s application for recusal was deemed moot, as it was made only in the event that the matter was referred back to the lower court.

2. Subject of Appeal and Admissibility Requirements:

The Federal Supreme Court recalled that in administrative court appeal proceedings, only legal relationships that have been the subject of a prior binding ruling by the competent administrative authority in the form of a ruling may be reviewed. If such a ruling is lacking, there is no subject of appeal and thus no admissibility requirement for a judgment on the merits (BGE 144 I 11 para. 4.3; 134 V 418 para. 5.2.1; 131 V 164 para. 2.1). This applied both to the lower court and to the Federal Supreme Court proceedings (Art. 86 FSCA). Therefore, the Federal Supreme Court did not entertain applications concerning criminal liability of authorities, claims for damages and compensation, as these were not the subject of the proceedings.

3. Arbitrary Factual Findings and Principle of Specific Objections:

The appellant alleged that the lower court had arbitrarily established the facts by omitting important facts. The Federal Supreme Court recalled that it may only correct or supplement the lower court’s factual findings ex officio if they are obviously incorrect or based on a violation of law within the meaning of Art. 95 FSCA and the deficiency could be decisive for the outcome of the proceedings (Art. 97 para. 1 and Art. 105 para. 2 FSCA; BGE 145 V 57 para. 4). Arbitrariness exists if the lower court draws obviously untenable conclusions, disregards significant evidence or ignores it without justification. Such deficiencies must be clearly and specifically set out in the appeal (Art. 106 para. 2 FSCA). The appellant’s objections, however, related predominantly to matters outside the subject of the appeal, so that arbitrary findings or a violation of the principle of investigation were ruled out from the outset.

4. Merits of the Cost Sharing:

The lower court had reduced the appellant’s cost sharing by CHF 15 to CHF 2,034.10, as the discharge day was not included in the calculated hospital days (Art. 104 HIO). The appellant argued that, in addition, the admission day should not be charged to him and contended that he had been unable to eat on another day for medical reasons, so that the cost sharing should be waived. The Federal Supreme Court dismissed these objections as inadmissible new claims (Art. 99 para. 1 and 2 FSCA). The appellant had also contested the accuracy of the hospital invoice and claimed that he had not been provided with a copy of the invoice, so that he could not verify its accuracy. The Federal Supreme Court relied on case law (9C_233/2008 dated 3 June 2008), according to which the health insurer’s entitlement to…