Cost absorption for change of dentist
Current decision of the social court Frankfurt am Main on the unreasonableness of further treatment by a dentist (SG Frankfurt, decision of 07. March 2019 – S 18 KR 2756/18 ER).
Background:
Health insurance policyholders can choose their doctor or. Dentist basically free to choose. In addition it says in § 76 paragraph 1 sentence 1 SGB V:
“The insured persons may choose among the physicians authorized to provide contractual medical care, the medical care centers, the authorized physicians, the facilities authorized or participating in outpatient care pursuant to § 116b, the dental clinics of the health insurance funds, the health insurance funds' own facilities pursuant to § 140 para. 2 sentence 2, which is required under § 72a para. 3 physicians and dentists contractually obligated to provide medical treatment, hospitals licensed to perform outpatient surgery, and facilities pursuant to Section 75 Para. 9 choose freely.”
However, the right to choose one's own doctor is subject to restrictions, especially in the case of dental prostheses: according to the case law of the Federal Social Court, the doctor cannot be freely chosen during the period until completion of treatment that has already begun. This generally applies even during the warranty period and in cases where the denture proves to be unusable.
For fillings and dental prostheses, the warranty period under Section 136a (4) sentence 1 SGB V is generally two years.
However, the restriction on free choice of physician does not apply if the patient cannot reasonably be expected to receive treatment from the previous physician. However, because the relationship between doctor and patient is characterized by special trust, case law does not place high demands on this unreasonableness.
Current decision:
The social court had to decide on an application in interim legal protection proceedings whether the insurance company has to bear the costs for rework of dentures by another dentist.
An expert had determined that the dental prosthesis in question required very frequent reworking due to an unfavorable initial situation and that complete freedom from complaints could only be achieved after three months. However, the number of reworkings was not unusual and therefore did not yet lead to unreasonableness, according to the court.
The court justified the unreasonableness however independently with a destroyed confidence relationship between physician and patient. It has stated in this respect “that mutual accusations are made by the applicant and the dentist and that there are diverging views on relevant circumstances of the treatment.”According to the file, the dentist stated that she could not understand the patient's pain and that the patient had not provided any precise information about her complaints. The patient told the dentist that she was helpless and unable to make proper dentures. In addition, the dentist and patient disagreed on whether the denture touch-up had been successful.
Against this background, the Social Court stated,
“that there are not merely certain disgruntlements between the applicant and the dentist, which would not justify unreasonableness of further rectifications with this dentist. Rather, the relationship of trust appears to be destroyed, so that it is not reasonable for the applicant to continue to be referred to the previous practitioner.”
The patient's insurance company was therefore provisionally obliged by way of an interim injunction to bear the costs of any necessary touch-ups by another dentist. The decision is final.
Conclusion:
If the relationship of trust between doctor and patient is destroyed, further treatment by the previous doctor may be unreasonable and the rectification by another doctor may be carried out at the expense of the insurance company. However, mere disgruntlement or the fact that rectification is required at all is not usually sufficient.
If you have a very conflictual relationship with your treating dentist or. the relationship of trust is destroyed, but your insurance company does not agree to rectification by another doctor, a specialized patient advocate can support you in asserting your claim.