- Dormant Procedures Are Not As Calm As It Seems Part 2 -
The following letter is so long and tedious to read? Possible. Please read carefully the patient at the checkout "with the capital T".
"Your application to cover the costs of a liposuction
Dear Mrs ….,
However, the currently applicable legal situation does not allow us to assume the costs of the requested Liposuction. Therefore we would have to reject your application at this point in time.
However, the Federal Joint Committee (G-BA) is currently examining whether the costs of liposuction for lipedema can be covered by the statutory health insurance companies. This can mean that we will be able to bear the costs for this treatment method in the future. For this, however, a corresponding positive decision by the G-BA must first become legally binding. As long as this is not available, your application - as already explained - must be rejected.
However, we would like you to benefit from a possible positive decision by the aforementioned committee. We therefore suggest the following procedure:
With the attached declaration you agree to a suspension of the application.
- If the G-BA should come to the conclusion that the costs for liposuctions are to be covered by the statutory health insurance providers as part of the statutory health insurance, we would also take this decision into account for the treatment you are now applying for. So we would also cover the costs retrospectively.
- If, on the other hand, the G-BA finds that recognition of the therapeutic benefit of the method and its medical necessity and economic viability cannot be determined, your application or objection procedure would be continued - if you so wish.
If you agree to our proposal, you will not suffer any disadvantages. Of course, we will inform you immediately after the G-BA decision is announced about its content and how to proceed.
Mit freundlichen Grüßen
This letter was often followed by such a suspension agreement:
"The parties involved hereby declare the suspension of the administrative procedure in the application for the assumption of costs for a liposuction. The suspension of the administrative proceedings does not mean that any claims will be lost. "
In this way and with a few modifications, the health insurance fund "with the capital T" made a proposal to suspend the procedure from 2015 to approx. July 2017 to patients who had applied for benefits for surgical therapy for lipedema. Many accepted this proposal, some did not. Some of these proceedings are currently being converted into objection proceedings.
Possible fictional approval - what needs to be done?
There is a statute of limitations of four years in social law. This is how long z. B. a review request according to § 44 SGB X can be made retrospectively.
All patients who have seen such a suspension agreement should consider whether either a request for a review according to § 44 SGB X is filed or an objection is filed in the case of a (current) rejection notice; Even if the objection period has already passed, it may be interesting to reopen the procedure.
Because: In almost all of these cases there is a fictitious approval (!), as no final decision was made (SG Trier, Az. S 1 KR 237/16; opinion confirmed by LSG Rhineland-Palatinate, L 5 KR 18/18).
Please also see my approval fiction article in the Lipedema Mode Jurablog "Dormant proceedings are not as calm as they seem" read.
And - especially in the case of applications that were made from around mid-April 2015, please urgently a) submit a review application or b) raise an objection with a rejection notice if the suspension is lifted. This does not have to be justified immediately. Because we remember: If the health insurance company does not decide on an application within the statutory period, it is considered approved (Section 13, Paragraph 3 a SGB V) and the costs are to be assumed or reimbursed.
RecAttorney Ruth Leitenmaier