Everyone or everyone who has to deal with the legal facets of our disease sooner or later comes across the term Approval fiction.
Stimulating topic approval fiction
Hardly any legal construction has heated the minds as much in recent years as the fiction of approval. For everyone who does not know what to do with this term (I ask for your understanding for the professionals among you, but not all patients know that), a description of this ingenious and also very controversial construct of the Patient Rights Strengthening Act that came into force on 26.02.2013 :
In general, an application for benefits made to the health insurance company is considered approved if the health insurance company does not make a decision within the statutory period (3 weeks, if the MDK is involved, 5 weeks).
There is already a lot of jurisprudence from the Federal Social Court, which I am referring to here in the Jurassic lipedema blog I'll come back to this a few more times. Don't worry, social law is anything but “dry”.
Disclosure or internal decision-making?
The subject of fictitious approval is also far too broad to be dealt with in a blog post. Therefore, I am picking out the following here: The Federal Social Court (BSG) decided on 11.07.2017/1/26 (file number: B16 KR XNUMX/XNUMX R) that not the internal decision-making of the health insurance company, but those Announcement of the administrative act as such is relevant.
Change in case law in 2017
What does that mean now? Before that, it was hotly controversial and unclear whether the date of the notification should really count as the time of the administrative decision of the health insurance company. Often the date fell and falls with the end of the three or five week period. It's annoying when you've just been happy to find a nice, tangible permit fiction. And asked himself:
Can that be? I am not yet aware of the rejection letter from the health insurance company at this point in time. And before this one is dispatched, I cannot yet know him.
What does the Federal Social Court say on this subject?
This feeling is not deceptive. Section 37 (2) SGB X states that an administrative act with access is deemed to have been announced. The intention of the institute for internal decision-making (read in the judgment of the Social Court of Würzburg, Az. S 11 KR 100/14, dated January 15.01.2015, XNUMX) was that, due to the not particularly long decision period for the funds after the legal reform, they would not additionally be exposed to the risk of To be charged by post.
The BSG creates the balance here by regularly assuming a 3-day fiction (date + 3 days) as the delivery time. Unless another point in time can be proven.
Request for review
Finally, a note: If you were disappointed that the deadline corresponded exactly to the date of the notification and then - as it was so beautifully put in earlier times - you “threw the beggar”: Submit a review request according to § 44 SGB X, preferably with expert support . The request for a review can be submitted retrospectively for up to four years.
More on this topic and other legal topics soon on the Jura Lipedema Blog,
All contact details of Ruth Leitenmaier on www.kanzlei-leitenmaier.de