Often, when discussing operative therapy and the occurrence of a Approval fiction the aspect of applying for liposuction with lipedema is neglected. But right here there are some hooks and eyes, of which I would like to highlight two of the most important, as these can lead to the victory of the opposing health insurance company, especially in a lawsuit - although everything would actually fit. Even the most subtle legal argumentation cannot always help over the unevenness of the application.
Applying for a liposuction - considered procedure
Usually, the applicant is already in a situation in which the level of suffering is relatively great, or at least felt so. This often means that the "close your eyes and through" principle is used. But especially here it is important to proceed as with a chess game - as cool and deliberate as possible - but not as with a virtual car race, in which a repeated crash does not matter. Because often there is only one chance.
Many of you will think here: That is typical lawyer, to say something like that, to act coolly and deliberately in such a situation, that is not possible. But I insist that you proceed carefully with such an application, in your own interest and also to avoid additional psychological stress. We already have to put a lot of energy into coping with our illness.
Restriction to one private service provider
An important point is the fact that often only the treatment is requested from a private doctor. As patients, we of course know that private doctors are represented to a large extent in the field of liposuction for lipedema, many complain that it is difficult to find a suitable "contract clinic" (in social law specialist jargon this means: "approved hospital according to § 108 SGB V ") to find. However, the current BSG case law must be observed here. This states that a fictitious approval can only occur if the application is also fictional. An important point: The applicant must be able to consider the service subjectively necessary.
Right here the rabbit is in the pepper. If the application is only for treatment by a private doctor, the treatment sought is not system-compliant. Our health insurance system is based on the principle of solidarity, which also means that, within this system, only the services of doctors who are within this system should be used (= contract doctors and contract clinics). Is actually also logical, but not without problems with liposuction for lipedema, since the supply situation is currently (according to my subjective opinion) inadequate.
However, I can only recommend you here: Please also take care of a doctor's report from a contract clinic when applying for a liposuction, because sometimes there are also undetected treasures here that have to be dug up first. Your application should not be aimed exclusively at treatment by a private doctor.
Too little lead time
A second very important point is the fact that such an application is made a few days before the first operation. Understandable if you consider everything that needs to be regulated, how high the level of suffering is and everything that goes through your head; it is often difficult to keep track of things. As long as you do not fall back on yours truly: create a checklist with the relevant to do's.
The statutory decision-making period for the health fund within the meaning of Section 13 (3) a SGB V is three weeks. If the medical service of the health insurance companies is involved, this period is five weeks (here the health insurance company must inform the patient; a certain form is not required).
In this respect I can only recommend everyone: You have often waited so long for the operations; please take the time to observe these deadlines and do not calculate them too tightly.
Please also note that separate regulations apply to private patients. This will be the content of a separate article.
With this in mind, I wish you every success with your application for a liposuction!
Your lawyer Ruth Leitenmaier