Nicotine replacement drug not from the health insurance

BSG sees no equality violation against alcohol and drugs

Legally insured smokers are not entitled to smoking cessation drugs. The corresponding legal exclusion is lawful and in particular not contrary to equality, ruled on Tuesday, May 28, 2019, the Federal Social Court (BSG) in Kassel (Az: B 1 KR 25/18 R).

The plaintiff probably wants to go to the Federal Constitutional Court. The legal exclusion of services is unconstitutional; he particularly violates the principle of equality. Because in the case of alcohol addiction and illegal drugs, the cost of drugs or replacement drugs is possible.

She is 71 today and claims to have smoked since she was 18. She is now suffering from a chronic disease of her lungs and airways. Numerous attempts to get rid of nicotine addiction have so far failed.

Therefore, she asks her health insurance company to cover the costs of smoking cessation therapy. According to a corresponding guideline, this included behavioral therapy discussions and nicotine substitutes, such as plasters or lozenges. With this combination, the chances of success are significantly better than with just one of these treatments.

On the sidelines of the negotiation, Professor Klaus-Dieter Kolenda, Vice President of the German Society for Nicotine and Tobacco Research (DGNTF) in Frankfurt confirmed this. With a combination of the offers, the chances of success increased from 20 to 30 to 40 percent. This is a good value in addiction treatment. Every year there are 120,000 deaths from tobacco use in Germany.

However, the health insurance company referred to the legal regulations. Thereafter, both behavioral therapy and the reimbursement of costs for medication are excluded.

The BSG now emphasized that treatment by psychotherapists is excluded, but not behavioral therapy discussions within the framework of special care programs, so-called disease management programs, by trained doctors. These are then obliged to provide the service. To what extent the remuneration is sufficient for this, the BSG can only check on a doctor's complaint, but not here on a patient's complaint.

In general, the health insurance companies would not have to pay for drugs to quit smoking. The legislator saw the increase in the quality of life in the foreground in a manner that was also constitutionally permissible and therefore excluded the assumption of costs - similar to appetite suppressants and sexual enhancers. The fact that the treatment can also have health reasons does not make this legislative assessment inadmissible.

The exclusion serves to limit costs in statutory health insurance. In addition, the costs for the insured are not too high. In return, they would save a lot if they stopped smoking, according to the BSG. mwo / fle

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