Successful Appeal Against Health Insurance Denial

In our specific case, a momo tricycle. was prescribed by the doctor, but the health insurance company rejected coverage. The family filed an appeal against the decision of the health insurance company, arguing that the therapy tricycle was medically necessary.

As a manufacturer of rehabilitation technology for children and adolescents with disabilities, we produce our aids individually for our customers based on their needs and preferences, always considering current medical and therapeutic insights. For families, aids are a support in daily life, and for children and adolescents, they often represent a step toward independence and development. However, just because an aid is recommended by therapists and prescribed by a doctor, it does not automatically mean that the aid will be provided at home.

The final decision on whether the child receives the aid usually lies with the health insurance company. This means that the insurance company may not recognize the necessity or cost-effectiveness of the aid, or it may consider it not to be a general everyday item. In such cases, the coverage for the aid is denied. Families are then left with the option of covering the costs themselves, which is often financially impossible. A second option is to file a legal appeal against the decision of the health insurance company.

Court Ruling

The court declared the lawsuit admissible and well-founded, ruling that the decision by the defendant, which denied the plaintiff coverage for a therapy tricycle, was unlawful and violated the plaintiff’s rights. It was therefore established that the plaintiff is entitled to a momo tricycle. in an adapted size with the corresponding accessories.

The court’s ruling is based on the provisions of the Social Code (SGB V). According to § 27 Para. 1 Sentence 1 SGB V, the plaintiff is entitled to medical treatment if it is necessary to diagnose, cure, prevent the worsening of a disease, or alleviate symptoms.

This entitlement also includes the provision of aids according to § 27 Para. 1 Sentence 2 No. 3 SGB V, if the aid is necessary in the individual case. The court made a distinction between immediate and indirect disability compensation and concluded that the therapy tricycle serves immediate disability compensation. Therefore, it is necessary as part of a doctor-supervised medical treatment.

Referring to the case law of the Federal Social Court (BSG), the court found that the therapy tricycle is specifically used in the context of doctor-supervised medical treatment to ensure its success. The alternative suggested by the defendant, a leg movement trainer, was deemed unsuitable. The lying position in the trainer would have adverse effects on the plaintiff’s reflux disease. The court therefore decided that the provision of the momo tricycle. was necessary to ensure the success of the medical treatment.

Plaintiff’s Argumentation

The plaintiff argued that the therapy tricycle was medically necessary. It had been prescribed by the attending pediatrician on 15.05.2020 and was intended as a supplementary measure to physiotherapy. It supports the mobilization of the knee and hip joints, reduces muscle tone in the legs, improves coordination, and helps to prevent constipation.

Additionally, it was emphasized that the therapy tricycle promotes the plaintiff’s mobility and secures the success of the medical treatment through this measure. The alternative suggested by the defendant was considered unsuitable due to the negative effects of the lying position. It was also argued that the therapy tricycle supports the social integration of the plaintiff and promotes participation in family life and activities with peers.

Rationale for the Ruling

The plaintiff’s legal representation also relied on the unlawfulness of the defendant’s decision. They argued that the plaintiff has a direct right to the therapy tricycle as a benefit in kind according to §§ 27 Para. 1, 33 Para. 1 Sentence 1 SGB V. They argued that the therapy tricycle is necessary for medical treatment because it supports the restoration of physical functions and complements physiotherapeutic measures. Since the device serves immediate disability compensation, its provision is considered indispensable.

The legal representation referred to the doctor’s prescription from 15.05.2020 and pointed out that there was no equivalent alternative that would be medically as effective but less costly. The leg movement trainer proposed by the defendant was particularly unsuitable due to the unfavorable lying position. Furthermore, it was emphasized that the therapy tricycle is not only medically necessary but also of importance for the plaintiff’s social participation.

In summary, the court confirmed that the plaintiff is entitled to the momo tricycle. to support the necessary medical treatment and facilitate integration into social life. The defendant was ordered to cover the costs because its denial was unlawful and violated the plaintiff’s rights.

This case demonstrates that an appeal against a health insurance denial can be reasonable and successful in justified cases. For our products, we offer free legal advice in the event of a denial. Simply contact your medical supply store or our field service for assistance!