Insurance reimbursement for medically necessary physiotherapy

24 C 967/05Tribunal de Primeira Instância29 de dez. de 2005Direito civilDeferido

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Extraído pela Omnilex

Resumo Omnilex

Following an oral hearing, the Düsseldorf Local Court ordered the defendant insurer to pay the plaintiff EUR 119.40 plus 4% interest from 10 August 2004. It also granted declaratory relief requiring reimbursement of future physiotherapy costs at 100%, after the contractual deductible, while the insurance relationship continues, if treatment is physician-prescribed and medically necessary and the fee is customary. The defendant was ordered to bear the costs of the proceedings. The judgment was declared provisionally enforceable.

Sumário Omnilex

An insurer’s obligation to reimburse physiotherapy costs may be established for future treatment subject to conditions defining covered care: reimbursement is due only for treatment prescribed by a physician, medically necessary, and remunerated at the customary rate, and remains subject to the contractually agreed deductible. The declaration of continuing coverage is limited to the duration of the insurance relationship.

Texto completo

Amtsgericht Düsseldorf — 24 C 967/05 — Urteil

Entscheidungsdatum: 2005-12-29

Aktenzeichen: 24 C 967/05

ECLI: ECLI:DE:AGD:2005:1229.24C967.05.00

Dokumenttyp: Urteil

Spruchkörper: Richter

Tenor

hat das Amtsgericht Düsseldorf

auf die mündliche Verhandlung vom 23. November 2005

durch den Richter am Amtsgericht X

für R e c h t erkannt:

Die Beklagte wird verurteilt, an den Kläger 119,40 EUR nebst 4 % Zinsen seit

dem 10.08.2004 zu zahlen.

Es wird festgestellt, dass die Beklagte zukünftig für die Dauer des Bestehens

des Versicherungsverhältnisses verpflichtet ist, die anfallenden Kosten für phy-

siotherapeutische Heilbehandlungen in Höhe von 100 % nach Abzug der jeweils

vertraglich vereinbarten Selbstbeteiligung zu Gunsten des Klägers zu erstatten,

soweit diese Behandlungen ärztlich verordnet und medizinisch notwendig sind

und die Vergütung üblich ist.

Die Kosten des Rechtsstreits trägt die Beklagte.

Das Urteil ist vorläufig vollstreckbar.

Palavras-chave

insurance coveragephysiotherapymedical necessityreimbursementdeclaratory relief

Questões jurídicas principais extraídas pela Omnilex

Whether the defendant must reimburse the plaintiff EUR 119.40 for physiotherapy costs, with interest.

The defendant must pay EUR 119.40 plus 4% interest from 10 August 2004.

Whether the defendant must reimburse future physiotherapy costs during the insurance relationship.

The defendant must reimburse 100% of eligible costs after the contractual deductible, provided treatment is medically necessary, prescribed by a physician, and charged at the customary rate.

Allocation of the costs of the proceedings.

The defendant bears the costs of the proceedings.

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