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Verdict: Health insurance company must not give up dementia patients


LSG Stuttgart awards her medical rehabilitation

Health insurance companies must not simply give up dementia patients. "Even with advanced dementia, the existence of rehabilitation ability and a positive prognosis for an inpatient rehabilitation measure cannot be ruled out," emphasized the State Social Court (LSG) Baden-Württemberg in Stuttgart in a recently published judgment of July 17, 2018 (Ref .: L 11 KR 1154/18). It awarded a 78-year-old woman reimbursement for a four-week rehab.

The woman has had Alzheimer's since 2013. The neurologists who treated her endorsed and applied for inpatient rehabilitation in 2016 in a therapy center that is specifically geared towards Alzheimer's patients. There is mild to moderate dementia of the Alzheimer type. With inpatient treatment, the course of the disease can probably be influenced favorably. Doctors named physical and mental activation and “help for partial self-help” as the goals of the rehab.

The medical service of the health insurance (MDK) activated by the health insurance company was of a different opinion. The woman was not able to do a rehabilitation measure and there was therefore no positive prognosis. The MDK did not address the specific clinical picture and the goals stated by the doctors.

Based on the MDK report, the health insurance company refused to cover the costs of the excess of 5,600 euros.

But the expert opinion was far too general and the rejection was therefore illegal, judged the LSG Stuttgart. The MDK's statements were "speculative" that the MDK had not assessed the type and severity of the disease. The MDK had not even checked the treatment goals cited by the doctors, which should be the primary focus here.

"The right to rehabilitation requires treatment, rehabilitation ability and a positive rehabilitation prognosis," explained the Stuttgart judges. "All three requirements were met." This results from the statements made by the treating neurologists in advance.

The fact that these assessments were correct was subsequently confirmed by the therapy center's discharge report. After that, the woman became more communicative and familiar with other people, and her general mood also improved. Her motor skills and endurance had also improved, so that she was able to walk over three kilometers with a walker. mwo / fle

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Video: Battling with Alzheimers disease: Zahra Moussavi at TEDxWinnipeg (August 2020).