File number: 6 O 123/ 18
Announced 8.7.2021
IN THE NAME OF THE PEOPLE
Judgment
In the legal dispute
of Mr. *** ,
plaintiff,
attorney at law: Bernd Brandl, Neusser Straße
182, 50733 Cologne,
against
, *** Krankenversicherung AG, *** ,
defendant,
attorney at law: Rechtsanwälte ***
, the 6th Civil Chamber of the Regional Court of Kleve, , on the basis of an oral hearing held on * by the Vice-President of the Regional Court, Dr. *** and a judge at the Regional Court, Dr. ***. Civil Chamber of the Regional Court of Kleve
on the basis of an oral hearing on *
by the Vice-President of the Regional Court Dr. ***, the judge at the Regional Court Dr. *** and the judge at the Regional Court Dr. ***
ruled in favour of the defendant:
The defendant is ordered to pay the plaintiff € 42,180.00 plus interest at a rate of 5 percentage points above the prime rate from * and to indemnify him against his legal representative for pre-trial legal costs of € 1,706.93 plus interest at a rate of 5 percentage points above the prime rate from *.
The costs of the legal dispute are imposed on the defendant.
This judgment is provisionally enforceable against the provision of security amounting to 120% of the amount to be enforced in each case.
Facts
The plaintiff is claiming benefits from the defendant under a private medical expenses insurance policy for the costs of an inpatient hospital stay.
The plaintiff maintains a private medical expenses insurance policy with the defendant under policy number *** in accordance with tariff ***. Reference is made to the insurance certificates dated *, * and * (BI. 54 et seq. of the file). The insurance contract is based on the “Model Terms and Conditions (MB/KK 2009)”, the “Tariff Terms and Conditions of *** Health Insurance” and the “Medical Expenses Tariffs ***, *** and ***, for details of which please refer to BI. 59 et seq. of the file.
The tariff conditions for *** health insurance contain the following provision in § 1 I (2)
“An insured event is the medically necessary treatment of an insured person due to illness or the consequences of an accident. …”
and in § 4 I (4) the following provision
“In the case of medically necessary inpatient treatment, the insured person
has a free choice of public and private hospitals that are under permanent medical supervision, have sufficient diagnostic and therapeutic facilities and keep medical records.”
“Somatization disorder (F45.0+G)” and in which the option “emergency” was ticked, the plaintiff was treated as an inpatient at the * clinic in Bonn from * to *.
The * clinic submitted an “application for assumption of costs” to the defendant under * (Annex K 3. BI 11 et seq. of the file) and a “1st application for extension” under * (Annex K 4, BI 16 et seq. of the file). In a letter dated * (Exhibit K 5, BI. 20 d.A.), the defendant, referring to a neurological-psychiatric expert opinion it had obtained from Dr. *** (BI. 21 ff. d.A.), stated that it would not assume the costs. The reason given was that inpatient psychotherapy was not medically necessary because the outpatient treatment options had not been exhausted. In a letter dated * (Annex K 6, BI. 27 et seq. of the A.), the *** clinic lodged an “objection” with the defendant.
The *** clinic invoiced the plaintiff a total amount of € 45,580.00 for the inpatient stay from * to * (invoices Annexes K 7 to K 19, BI. 29 et seq. of the A.), The payment of this amount less an amount of € 3.400.00 for optional services, after the defendant had informed him in a letter dated * (Annex K 21, BI. 45 f. d.A.) that it would maintain its refusal to assume the costs.
The plaintiff is of the opinion that his inpatient stay in the *** clinic in Bonn from * to * was medically necessary in order to treat a somatization disorder, as well as balance disorders. The plaintiff claims that it was medically necessary to treat pain and pulsating pressure in the paranasal sinuses, tingling in the feet and hands, fasciculation in the calves, aching wrists, nausea and a feeling of weakness in the extremities; in particular, the stay was also medically necessary beyond the second week.
The plaintiff requests that
the defendant be ordered to pay him € 42,180 plus interest at a rate of 5 percentage points above the prime rate from * and to indemnify him against
pre-trial legal costs of 1,700.93 plus interest at a rate of 5 percentage points above the prime rate from the pendency of the proceedings (*).
The defendant requests that
the action be dismissed.
It is of the opinion that the inpatient treatment in the *** clinic was not medically necessary. It claims that there was no basis for the medical indication of psychiatric inpatient treatment. There was no danger to herself or to others. In fact, outpatient treatment consisting of close-meshed psychotherapy of initially 25 hours and guideline-based psychopharmacotherapy was indicated. The indicated and necessary outpatient treatment options had not been exhausted. They were repeatedly suggested but not used without medical reason. At best, partial inpatient psychotherapeutic treatment would have been indicated, but not the inpatient treatment carried out over a period of three months. Insofar as the plaintiff referred to an emergency admission, the requirements for inpatient admission were not met. Insofar as the plaintiff submitted medical documents, the correctness of their content is disputed with ignorance; this applies in particular to the findings, diagnoses and conclusions drawn from them. Finally, the defendant is of the opinion that the medical necessity of the treatment in dispute is not to be assumed from the second week onwards pursuant to Section 192 (8) VVG.
For the remainder of the parties’ submissions, reference is made to the written submissions submitted by the parties to the file together with the annexes.
On the basis of the decisions of * (BI 81 d A) and * (BI. 407 d.A ), the Chamber took evidence by obtaining a written psychosomatic expert opinion from Univ.Prof. Dr. med. *** from ***, the details of which can be found in BI. 422 et seq. of the file, as well as by hearing the expert at the hearing on * (BI. 494 et seq. of the file)
Reasons for the decision
The admissible action is successful on the merits. The plaintiff has a claim for reimbursement of € 42,180.00 against the defendant on the basis of the medical expenses insurance contract at issue in conjunction with §§ 1 S 1, 192 Para. 1 VVG.
According to § 1 I (1) of the tariff conditions for *** health insurance, the defendant as insurer offers insurance cover for illnesses and provides reimbursement of expenses for medical treatment and other agreed benefits in the medical expenses insurance. The insured event is the medically necessary treatment of an insured person due to illness or the consequences of an accident, § 1 I (2) of the tariff conditions for *** health insurance.
The plaintiff has provided the evidence incumbent upon him that he suffered from an illness for the treatment of which the inpatient treatment at issue was medically necessary. On the basis of the written report of the expert Univ-Prof. Dr. med. *** and his statements at the hearing on *, the Chamber is convinced that the plaintiff suffered from a somatization disorder according to ICD-10 F45.0 and a moderate depressive episode according to ICD-10 F32.1 at the time of his admission to the *** clinic. The detailed written and oral explanations of the expert are comprehensible, coherent and overall convincing. The Chamber can fully endorse them.
On the basis of a careful evaluation of the findings and his own examination of the plaintiff, the expert came to the detailed and well-founded conclusion that the defining characteristics required for the classification of the above-mentioned disorders apply in full to the plaintiff.
The expert convincingly demonstrated that the findings submitted and the plaintiff’s own statements provided a sufficiently reliable basis for the result he arrived at. The expert explained that the documents in the file were completely sufficient in their scope for the diagnosis, especially as he had been able to establish sufficient consistency with the plaintiff’s own descriptions. On the one hand, the expert relied on the information provided by the plaintiff himself, which he considered sufficiently critically against the background of the passage of time and the fact that these were the plaintiff’s own perceptions, and placed them in relation to the doctor’s letters, discharge reports and reports of findings in the file. In doing so, the expert stated that these all came from licensed physicians, which is why he – also rightly in the opinion of the Chamber – believed them sufficiently and therefore assumed the physical complaints described therein. In view of this, the defendant’s blanket denial or declaration of ignorance regarding the medical findings is also pointless. Doubts about the correctness of the findings are not apparent in the slightest and are also not presented. Specifically, the circumstance of the numerous physical complaints described by the plaintiff and listed in the medical reports and the associated visits to the doctor over a long period of time are – according to the expert comprehensibly – according to the relevant guidelines what justifies the diagnosis of a
somatization disorder, especially since this also follows directly from the findings reports under differential diagnostic discussion and results in the result of a somatization disorder in a classic manner.
The expert explained in detail and convincingly that the relevant criteria for an indication for inpatient treatment were sufficiently clear. It is true that the principle of “outpatient before inpatient” also applies in the psychosomatic field. However, there are criteria that justify inpatient admission as medically necessary if previous outpatient treatment was not sufficient. The expert has convincingly explained that such a case exists here. It was correct to assume at the time that immediate and prompt admission to inpatient treatment was necessary. There were essentially three criteria for this. Firstly, the diagnosis of somatization disorder itself. In view of its considerable severity, this already implies inpatient admission according to the relevant guidelines. Added to this is the fact of comorbidity. In this case, a depressive disorder was present in addition to the somatization disorder, which was already considered to be particularly severe. Furthermore, outpatient therapy had been attempted, even if only for a very short time, without this having brought about a “hint of improvement”, which is why, in addition to the two criteria mentioned above, the assessment of hospital treatment as medically necessary was justified.
Based on the expert’s explanations, the Chamber is also convinced that the medical necessity of inpatient treatment could still be assumed at the time of the application for an extension on *. The expert explained that a discharge at the time of the application for extension, i.e. after only approx. 6 weeks, would have meant an exceptionally short period of treatment in order to achieve the ability to be discharged. In addition, there was also no outpatient possibility of the medically necessary multimodal treatment practiced here. This continued to make inpatient treatment medically necessary beyond the time of the application for an extension.
Furthermore, it was true that no further findings could be taken from the file regarding the time after the application for extension. However – according to the expert convincingly – the comprehensible and coherent statements in the application for extension, in particular also in comparison with the previous treatment documents in the context of an overall view
with the statements in the discharge report, which are to be critically assessed, justify the assumption that it was actually medically necessary to continue the inpatient hospital treatment until *. In addition, the fact that the treatment had led to a sustained improvement and that a period of 2 x 6 weeks is classically required for the treatment of a somatization disorder also supports this in the context of a clinical assessment.
The defendant has not countered the plaintiff’s implicit argument that the * clinic fulfils the
requirements of Section 4 I (4) of the tariff conditions for *** health insurance.
The defendant has not raised any objections to the calculation and amount of the conclusively submitted claim.
The interest claim and the indemnification claim with regard to the pre-trial legal costs and the interest claim in this regard follow from the aspect of default.
The decision on costs follows from Section 91 ZPO. The decision on provisional enforceability is based on Section 709 ZPO.
Value in dispute: € 42,180.