Fictitious approval required?

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,
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All contact details of Ruth Leitenmaier on www.kanzlei-leitenmaier.de

ruth laitenmaier lipoedem fashion lawyer

Author: Ruth Leitenmaier

My focus is on social and medical law, tax law, inheritance law and senior law. I myself am a lipoedema patient, had an operation in 2016 and I am grateful that I escaped a less than good fate. Besides my family, art and literature are my constant companions. I like being in the great outdoors and I also have my balance in sports.

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  • “Approval Fiction” - Never Heard Before 🙂 Thanks for the clarification!
    Nevertheless, I did not get very clever out of it - if the notification date and the deadline end date coincide, but a negative decision was issued too late due to the 3-day fiction - that means it is de facto a permit and the Checkout would have to pay the Lipo?

  • I applied for a liposuction and on April 26.4th Received a letter from Barmer that reads like a rejection, but where it doesn't say my application has been rejected. How do I deal with it now? The reasoning is that it is a private doctor who cannot be billed with via the health card and that he carries out the procedure on an outpatient basis. Do I object to the letter or do I submit a new application for the reimbursement of costs for an inpatient procedure in a contract clinic? Or should a letter that does not contain rejection be regarded as rejection either? Then what would that mean for me? I'm really at a loss right now. Kind regards, Manuela Gehring

  • I applied for a liposuction and on April 26.4th Received a letter from Barmer that reads like a rejection, but where it doesn't say my application has been rejected. How do I deal with it now? The reasoning is that it is a private doctor who cannot be billed with via the health card and that he carries out the procedure on an outpatient basis. Do I object to the letter or do I submit a new application for the reimbursement of costs for an inpatient procedure in a contract clinic? Or should a letter that does not contain rejection be regarded as rejection either? What would that mean for me then? I'm really at a loss right now. Kind regards, Manuela

  • Dear Ruth,
    Thank you for your exciting articles, which are very important for and lipedema patients.
    I haven't been able to find an answer yet. Is there a right to an official certificate (certificate) about the disease lipedema?
    I urgently need this for my operations and the health department does not want to issue it to me. Can i force this? Or are there any tips you can give?