A health insurance company may refuse to pay for care deemed unnecessary

Health insurers have the right to call on a first contact, also known as a “gatekeeper”, when the insured person uses different medical services that are not coordinated between them, a practice called «doctor shopping” or “medical shopping”. The Federal Court has just ruled in favor of Helsana, which opposed an Aargau policyholder.

The latter, benefiting from standard insurance with free choice of doctor, had consulted several psychiatrists before having her stomach reduced. But Helsana has decided to no longer pay for its treatments unless they are ordered by a first point of contact (gatekeeper). In short: the fund imposed an economic model on her (family doctor type), even though she had paid the most expensive premiums.

The Federal Court therefore follows Helsana: the fund has the right to use a gatekeeper in the event of medical shopping. “This approach is compatible with the principle of free choice of doctor,” considers the TF in a judgment published Monday.

He recalls that compulsory healthcare insurance (AOS) covers the costs of medical services provided that they are “effective, appropriate and economical”. However, Helsana concluded, on the basis of an expertise, that its insured had until then benefited from uncoordinated care which did not meet these criteria, considers the TF. Under these conditions, the fund has the right to impose a system providing for a treatment plan by a medical institution acting as a “gatekeeper”.

This way of doing things does not constitute an infringement of the fundamental rights of the Appellant, further considers the TF. Who also considers that “the fund’s approach may prove to be in the interest of the insured who is thus protected against medically unnecessary treatments.”

Patients and funds react