In a case regarding the reimbursement of heparin-induced extracorporeal lipoprotein precipitation (H.E.L.P) apheresis, the Federal Supreme Court has decided that the effectiveness of the treatment must be reassessed by the health insurance company. This could provide a possible legal precedent.
Christian Salzmann, who is affected by Long COVID, has tried numerous treatment approaches throughout his disease journey. For him, H.E.L.P. apheresis brought significant therapeutic success. Unfortunately, the procedure is very expensive; the cost of Christian Salzmann's treatment amounted to around CHF 20,000 for nine sessions.
His insurer Helsana refused to cover the costs for the treatment, claiming that the effectiveness of the treatment had not yet been sufficiently proven. The reasoning was based on the assessment of a Helsana medical examiner. Christian Salzmann and his lawyer Sebastian Lorentz took legal action against this decision.
After the Insurance Court of the Canton of Aargau initially dismissed the claim, the Federal Supreme Court ruled in February 2024 that the reasons given by Helsana were not convincing enough to refuse to cover the costs.
The aim of the lawsuit was to obtain a clear ruling from the Federal Supreme Court that the costs of the treatment must be covered, as the health insurer is unable to prove that it is ineffective, inappropriate, or uneconomical.
Even if this goal was not fully achieved, the ruling gives reason for hope. The decision clearly shows that an internal assessment is not sufficient to reject a treatment. This may also apply to reimbursement of other therapies if they were prescribed by a doctor.
For Christian Salzmann, the ruling means that his health insurance company will re-examine the case and decide again on the reimbursement. If coverage is still refused, he would have to take legal action again.
The Federal Supreme Court's decision is an important step for people affected by Long COVID.
For those affected, the decision could increase the chances of treatments that have not yet been scientifically proven being covered in future.
In the blog series “From our Community”, we regularly present treatments that are controversially discussed by people affected by Long COVID and healthcare professionals. We have already taken a closer look at apheresis in this context: click here to read the blog.
