Karlsruhe Social Court: Only if there is a genetic mutation, the health insurance must pay
Breast cancer in a breast does not have to be a reason for a preventive breast removal of the healthy breast. A precautionary removal of the healthy mammary gland and a subsequent breast build-up with implants is only possible at checkout costs if there is an increased genetic risk of breast cancer, the Social Court of Karlsruhe decided in a recently published judgment of June 22, 2017 (file number: S 14 KR 3991/16 ).
In the specific case, the plaintiff was diagnosed with a malignant tumor in the right breast in 2015. The mammary gland was finally removed. The woman's breast was rebuilt with implants.
However, she also wanted to have the mammary gland in her healthy left breast removed as a preventive measure. Then this breast should also be reconstructed with implants. Given her young age, the cancer could return to her healthy breast. Your statutory health insurance should cover the costs of the procedure. It is not reasonable that she has to wait for the onset of the disease, said the applicant.
But the health insurance company refused to pay the costs. The woman does not have the BRCA 1 or BRCA 2 gene mutations associated with a higher risk of breast cancer. Only then should removal of the healthy mammary gland be indicated.
The social court also followed. Removal of the healthy mammary gland with subsequent breast build-up without an existing gene mutation should be seen as a "new treatment method". In order for the health insurance company to pay the costs in such a case, a recommendation from the Federal Joint Committee must be available. The committee, in which health insurance companies, doctors and insured persons are represented, has not yet given such a recommendation.
It also does not correspond to the current state of science to carry out a prophylactic removal of the mammary gland with an increased risk of illness due to a young age of illness. A mere risk of illness has no inherent illness value and is therefore not life-threatening. The health insurance company should therefore not pay for the corresponding treatment. fle / mwo / fle