Anastasia Mamonova and Johannes Hillig
He would have had a chance to defeat cancer, to go on living, but the SLKK refused therapy for Karl Riebli-Föhn († 82) from Hergiswil NW. The Zürcher Krankenkasse did not want to cover the costs at all – although it had to. Because the Kymriah therapy is part of the basic insurance. But the SLKK preferred to go to court. And that cost the 82-year-old first time and then his life.
He died the day before the federal court ruled that he was right.
How can something like that happen? The fund justified the rejection by stating that the WZW criteria were not met. Accordingly, a treatment must be effective, appropriate and economical.
“Health insurance should offer customers pre-financing”
The health insurance expert Felix Schneuwly from the comparison service Comparis says to Blick: “This is a blatant case. Something like this can happen because the health insurance companies have to pay for such expensive treatments with a chance of success around 50 percent. Playing for time is not an option when it comes to life or death. ”
If a health insurance company goes to court in such a case, “it should at least offer the terminally ill customer to pre-finance the costs if the customer takes over the financing if the court should decide in favor of the health insurance company,” says the expert.
However, it is also the case that the person with basic insurance cannot always automatically count on the financing. “Even if treatment like Kymriah is a compulsory service, that does not mean that it has to be paid for in each individual case.” The guidelines drawn up by the health insurers’ medical officers are intended to ensure that all insured persons are treated equally in comparable situations. However, he still sees potential for optimization there.
BAG “acted too late”
The son of the deceased, Armin Riebli (52), not only criticizes the fund, but also the Federal Office of Public Health (BAG). As a supervisory body, this would not have done anything. The BAG, on the other hand, denies the allegations. It intervened and initiated regulatory proceedings. The investigation has not yet been completed.
The Comparis expert says that in this case the BAG “certainly acted too late”. The office does indeed do audits at the cash registers, “what is complained about there and whether the criticized cash register correct their mistakes quickly enough, the public does not find out”.
As it later turned out, Riebli-Föhn was not the only one to whom the SLKK had refused the same therapy. The other patient was able to afford the therapy without the health insurance and is now living on. Felix Schneuwly even knows a third, similar case.
Is the SLKK just a black sheep under the tills? “As long as the BAG does not create transparency here, I can only guess, but neither confirm nor deny it,” says Schneuwly.
“BAG must create more transparency”
However, he sees it as the duty of the authorities to create precisely this transparency. “The BAG must ensure that every health insurance company applies the law in the same way. I dare to doubt whether the BAG is actually doing enough to ensure that all insured persons are treated equally, regardless of which fund they are insured with. “
Parliament and the Federal Council would create more and more paragraphs, which would only “drive up bureaucratic and court costs”. “I fail to understand that the FOPH, together with the head of department, Federal Councilor Berset, holds an annual media conference on next year’s premiums, but not on supervisory activities. That would be very important in order to strengthen the population’s trust in a functioning system, ”emphasizes Schneuwly.
“There is unequal treatment in Switzerland”
In his opinion, regulation is going in the wrong direction. «Without a lawyer, policyholders have little chance of getting their rights. The health insurance law must be simplified again. In return, the BAG must be given the authority to exclude health insurance companies, doctors, hospitals, etc., who repeatedly fail to comply with the law. ”
Daniel Tapernoux from the Swiss Patient Organization (SPO) also calls on the authorities to act. “There is unequal treatment in Switzerland. In our experience, small and inexpensive health insurances tend to reject medication and therapies. The responsible authorities should finally do something here, ”he says to Blick.
He couldn’t say anything specifically about the SLKK. Due to the low number of reports that would reach the SPO, it could not carry out statistical evaluations for the respective health insurance companies.
“We regret the death of Mr. Riebli”
The Santésuisse health insurance association, of which the SLKK is a member, is sorry for the tragic case. «We very much regret the death of Mr Riebli and understand the pain of the relatives very well. Our condolences are due to them, ”says Santésuisse spokesman Michael Müller to Blick.
At the same time, he emphasizes that the assessment of each individual case and the related circumstances is the responsibility of the respective health insurer. “The health insurer then makes its decisions on the basis of this assessment. The federal government has defined this procedure, ”said Müller.
The SLKK itself does not want to comment on the case despite repeated inquiries from Blick.