OLG Karlsruhe: Marriage clause in private health insurance ineffective
The Oberlandesgericht (OLG) Karlsruhe is convinced that the limitation of reimbursement of costs for artificial insemination to married couples is not permitted in private health insurance. Unlike the statutory health insurance, there is no justifiable reason for this, as the OLG decided on Friday, October 13, 2017 (Az .: 12 U 107/17). According to this, there can also be a claim to reimbursement of costs without complete sterility if pregnancy were associated with high risks.
The applicant can get pregnant naturally. Because of a chromosome change, the probability of a successful pregnancy and a healthy child is less than 50 percent.
Before she married, she had tried to get pregnant through artificial insemination. This failed.
The woman's private health insurance refused to cover the costs. According to insurance conditions, a corresponding claim exists only for married couples. In addition, a partner must be sterile. This is not the case here, because the woman can get pregnant.
On the woman's complaint, the OLG removed both obstacles. However, because of the fundamental importance of both questions, the appeal to the Federal Court of Justice was permitted.
While private health insurance usually pays the full cost of artificial insemination, there is only half the subsidy in statutory health insurance. The restriction to married couples is prescribed by law there.
The OLG Karlsruhe is convinced that this is ineffective in private health insurance. Legislators can prescribe unequal treatment based on socio-political considerations. However, private insurers would pursue "exclusively economic interests". "Against this background, the distinction between married and unmarried insured persons who want to have children is arbitrary and the contract provision is therefore ineffective."
The fact that the plaintiff can get pregnant naturally does not prevent reimbursement of costs. To justify this, the OLG referred to the high risk of possible genetic damage to the egg cell. This is an illness for which the insurance company must be responsible. mwo / fle