Health insurance company has to finance new high-tech knee joint

LSG Darmstadt: Lower leg amputee can walk better with it
Statutory health insurance companies also have to pay lower leg amputees for particularly expensive prostheses to compensate for their disabilities. The prerequisite is that the costly aid offers a "significant benefit compared to the cheaper alternative", the Hessian State Social Court (LSG) decided in a judgment published on Tuesday, November 28, 2017 (file number: L 1 KR 211/15). The Darmstadt judges thus awarded a legally amputated pensioner the reimbursement of costs for a microprocessor-controlled so-called genium knee joint.

The 82-year-old had to have his left lower leg and knee amputated in 2012 due to a sports accident. His health insurance fund provided him with a 28,000 euro so-called C-Leg prosthetic leg system in July 2012. When he discovered the genium knee joint in rehabilitation a month later, he applied for this prosthesis from his health insurance company.

Just like the C-Leg, the almost € 46,000 Genium knee joint is also microprocessor-controlled. However, the health insurance company had to pay for the prosthesis because of significant advantages when walking and standing. Since the C-Leg could be partially used for the Genium knee joint, additional costs of around 26,000 euros would be incurred.

But the health insurance company refused to reimburse the Genium knee joint. The C-Leg is sufficient. The coveted knee joint does not offer any significant advantages in use.

In its judgment of November 9, 2017, the LSG contradicted. The health insurance company must reimburse the costs for the genium knee joint. The prosthesis replaces a part of the body and thus serves to directly compensate for disabilities. In such a case, aids should be granted if they offer "significant advantages" in everyday life in each individual case.

This is the case here. The sport-loving plaintiff could climb obstacles more easily with the Genium knee joint, stand on sloping ground and better climb stairs and backwards than with a C-Leg. With the Genium knee joint, the plaintiff achieved the highest degree of mobility four, with a C-Leg the degree of mobility with him was two to three. For the 82-year-old, who is about as fit as a 60-year-old, the genium knee joint is the only way to almost completely compensate for his disability.

The Federal Social Court (BSG) has already ruled several times on the reimbursement of prosthetic legs. On September 16, 2004, the Kassel judges ruled that the health insurance companies had to finance a C-Leg for immediate disability compensation because of the "essential benefits in use" (Az .: B 3 KR 1/04 R, B 3 KR 6/04 R and B 3 KR 2/04 R). Those affected could deal with everyday life much better than using mechanical prostheses. However, there is no entitlement to optimal care.

In addition to a normal running prosthesis, leg amputees can also claim a freshwater bathing prosthesis, according to the BSG on June 25, 2009 (ref .: B 3 KR 2/08 R and B 3 KR 19/08 R). This satisfies the need for mobility in the home bathroom or swimming pool. However, the health insurers would not have to pay for a special salt water prosthesis, as this does not satisfy a general basic need of everyday life (Az .: B 3 KR 10/08 R).

Special sports prostheses, for example in order to be able to play better badminton, should not be at the expense of the community of insured persons, the BSG judged on March 21, 2013 (ref .: B 3 KR 3/12 R; JurAgentur report of June 5, 2013). Because the promotion of leisure and club sports is fundamentally not one of the tasks of health insurance companies in the supply of medical aids. fle / mwo

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