28. Juni 2024 – In its decision of 29 May 2024, the Federal Supreme Court ruled on the appeal by A., a self-employed gynaecologist, against a health insurer B. The case concerned the reimbursement of ultrasound examinations during pregnancy under the compulsory health insurance (OKP).

The key question was whether health insurer B. was entitled to reclaim reimbursements already paid to A due to the fact that the latter did not hold the certificate of competence for pregnancy ultrasound, which would have allowed him to claim these services from the compulsory health insurance (OKP). The Cantonal Arbitration Court for Health Insurance Disputes of the Canton of Aargau ruled that no reimbursement was owed for these services and that the health insurer B. was entitled to reclaim them.

The court upheld the decision of the Cantonal Court of Arbitration for Health Insurance Disputes. The court also rejected A.'s argument that health insurer B.'s claim for reimbursement was forfeited because, when checking the invoices submitted by A., it should have realised that A. did not have the required certificate. The court emphasised its case-law according to which the relevant limitation period is not triggered by an unjustified reimbursement due to an error on the part of the health insurer. Rather, a so-called "second event" is required. This is the day on which the health insurer, exercising reasonable care, could have discovered its error later – for example, on the occasion of an invoice check or on the basis of an additional index.

For more information, see here.