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Doctors newspaper online, 27.08.2019
LSG judgment
In the absence of glandular tissue, the health fund does not have to pay for breast implants. There is also no enforceable right to participate in the testing procedure for liposuction, according to the LSG Baden-Württemberg.
By Martin Wortmann
As there is no standard size for women in breasts, the health insurance fund does not have to pay any additional costs, according to the LSG in Stuttgart.
© Schulz-Design / Fotolia
STUTTGART. Women with genetic missing glandular tissue can claim from their statutory health insurance no Mammaaugmentation with silicone implants. Because the impaired body function would not be treated as the Landessozialgericht (LSG) of Baden-Württemberg in Stuttgart ruled in a recently published judgment. Furthermore, insured persons can not assert a claim to participation in the testing of liposuction against their health insurance.
The now 32-year-old plaintiff had lost 76 kilograms after a gastric bypass surgery in May 2013. Remaining skin excesses on the entire body led to disfigurement and restricted mobility, inflammation and pain. She also suffered from painful lipoedema.
The female breast size basically does not represent an irregular body condition, as there is no standard size; Therefore, there is basically no claim to enlargement or reduction of the size of the breast.
From the verdict of the LSG Baden-Württemberg
On the recommendation of the MDK, her health insurance fund approved a total of five operations for tightening and further interventions on the abdomen, breasts, upper arms and thighs. On the other hand, the insurance company refused to pay for a stationary liposuction and breast augmentation with silicone prostheses.
Woman wants to get paid for enlargement
The woman complained of this. Like the Social Court of Karlsruhe, the LSG also dismissed the lawsuit. For breast augmentation, the Stuttgart judges stressed that the health insurance companies must only occur in the presence of disease. This is "an irregular physical or mental condition that results in either a need for treatment or disability or both".
"Deviations from the morphologically ideal norm", such as small or asymmetrical breasts, were generally not included. An "extreme and unreasonable amount" that could justify an exception is not available here.
No claim to liposuction
There is no claim to liposuction either. The Federal Social Court (BSG) in Kassel have confirmed that this does not belong to the cash benefits.
In addition, the LSG decided that the woman could not enforce a possible claim to participation in the planned testing of the liposuction with a lawsuit against the health insurance. Because this is not involved in the selection of study participants. In detail, the Stuttgart judges refer to the procedure provided for this purpose. Thereafter, patients can report independently from October 1 to December 31 of this year and independently of any endorsement by the health insurance on the homepage " www.erprobung-liposuktion.de ".
Patients are then examined by a medical examiner. If there are more suitable candidates than places, the lot should decide. The health insurances have no influence on this entire process, the LSG emphasized.
LSG Baden-Württemberg
Az: L 5 KR 447/17
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