SGK may sometimes reject requests for health benefits on the grounds of "not included in SUT" or "non-referral". Objection is possible.
SUT (Health Practice Communiqué)
- List of treatments/drugs to be covered by SSI
- Updated periodically
- Non-SUT treatment is not covered (as a rule)
Typical Reasons for Refusal
- Treatment is not included in SUT
- Without referral to a private hospital go
- Drug equivalent
- Referral requirement for non-urgent intervention
Opposition Methods
- Objection from SGK Provincial Directorate
- SGK General Directorate
- Suit in the labor court (in accordance with Article 4)
Emergency Exception
- Emergency within the scope of SGK is paid
- Referral is not required
- Even a private hospital is covered (if it is urgent)
- The definition of "urgent" is evaluated medically
Supreme Court 10th HD and 21st HD
10. HD and 21st HD adopt that SGK must prove its "not urgent" claim with concrete medical evidence, and that contrary to the medical reports, a decision will be made against SGK.
Practical Recommendations
- Keep all medical documents
- Emergency room records are critical
- Get SSI rejection letter
- Do not miss the deadline (60 days lawsuit)
SGK and health law lawyer recommended.