14. Juni 2024 – In its decision of 8 May 2024, the Federal Supreme Court partially upheld an appeal by the individual A., who obtained health insurance from EGK Grundversicherungen AG, against the decision of the Cantonal Administrative Court of Glarus concerning the coverage of psychiatric basic care by the mandatory health insurance (Obligatorische Krankenpflegeversicherung, OKP). A., suffering from a Fragile X syndrome with autism spectrum disorder, claimed reimbursement for psychiatric basic care provided by his mother. A.'s mother was employed by an organisation that was entitled to provide services at the expense of the mandatory health insurance (C. GmbH). However, she does not fulfil the criteria of a qualified care professional to provide psychiatric care services. This was not disputed before the Federal Supreme Court.

The Cantonal Administrative Court had denied the claim by A., arguing that A.’s mother lacked the necessary professional qualifications for providing psychiatric basic care services. The court overturned this decision, stating that the case law established in BGE 145 V 161 Consideration 5 on the provision of services by family members employed by an approved home care organisation was also applicable by analogy to basic psychiatric care within the meaning of art. 7 para. 2 letter c no. 2 Ordinance on Healthcare Benefits (Krankenpflege-Leistungsverordnung, KLV). It emphasized that no specific professional qualification was required for such care, as long as the person providing the care services was adequately instructed and supervised. In the present case, the court held that these circumstances were indeed present.

The court therefore partially upheld A’s appeal and overturned the decision of the Cantonal Administrative Court of Glarus and the previous appeal decision of EGK Grundversicherungen AG. The case was referred back to the health insurance company for re-evaluation of its obligation to cover the costs of the psychiatric basic care provided by A's mother.

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