Most peculiar. While the rejection process in the first case took three calendar months, the second attempt was completed within 24 hours. The new standard letter rejects everything across the board, with flimsy arguments and legal texts pulled by the hair, the invalidity of which I already proved in the first case. The courts will decide which of us is right.
I am left with the satisfaction that the AOK lawyers' heads must have been spinning in their search for a text that could be used in court. A text that means as much as we would be happy to cover the costs of your vital 1:1 care, even in hospital. But the stupid legislator is forcing us to send you to your death for - quote - economic reasons. I find it quite cute how I am repeatedly told that I have already been informed that I have to pay for my own care in hospital. You don't think I'm going to pay the 3,000.00 euros from this lawsuit myself without a dispute, after I didn't do that with the 50,000.00 euros from the first lawsuit.
Be that as it may. This is apparently now the AOK's new standard rejection policy:
Dear Mr Ruppelt.
We have received your message dated 21.02.2024. You can apply for the assumption of costs here
of outpatient intensive care by your nursing service during inpatient treatment.
at the Martha-Maria Clinic from 22/02/2024.
As we have already informed you, for the period of a hospital stay
outpatient intensive care cannot be prescribed (§ 37 c SGB V in conjunction with § 1 para.
5 Out-of-hospital intensive care guideline of the Joint Federal Committee (AKI-RL).
Also for the tent of the stay in other facilities in which, according to the statutory provisions
The patients are entitled to the provision of medical treatment care by this facility.
(e.g. rehabilitation), out-of-hospital intensive care cannot be prescribed.
be made. Whether such an entitlement to medical treatment care in these care
settings is to be examined by the health insurance fund on a case-by-case basis (cf. § 1 Para. 5 S. 2 and 3
AKI guideline).
Accordingly, as part of the individual case assessment, it may only be determined whether the facilities
benefits in accordance with Section 1 (5) sentence 2 of the AKI-RL already exist that are subject to the
Directive. In the facilities referred to in sentence 1 (hospitals and inpatient equivalent
psychiatric treatments), this is generally assumed.
Therefore, the requirements for an individual case decision for out-of-hospital intensive care are
during the inpatient hospitalisation and the costs can be covered by us.
unfortunately cannot be worn.
Pretty much bullshit. What the AOK is trying to say is that hospitals are entitled to care and that they can sue for damages. But that's a lie. There is no hospital with a health insurance licence that offers or can even provide the necessary 1:1 care. The care ratios stipulated by law do not allow for this. It's as simple as that.
So how the AOK claims to have established that the Martha-Maria hospital provided 1:1 care as part of its individual case review, I am looking forward to the review documentation. Of course I will request access to the files. Or are they referring to the last sentence, the basic situation, which is not always the case? Care key, and so on.
The whole story becomes even more exciting when you consider the previous agreement with the hospital that I would bring my own nursing service with me due to the 1:1 care that cannot be provided by the hospital and is not even planned. It's a great story that the AOK apparently knows better what the Martha-Maria hospital can provide in terms of care than the hospital itself. I can't wait to see what the AOK audit report says. I bet 1,000.00 euros to invest in one of the recognised nature conservation projects on https://shop.paddys.de/transparency/ . No kidding, it's a farce. Nobody at the AOK checked anything. I sent off the application on Wednesday afternoon at four, presumably just before closing time. The next morning at 8.41 a.m. I had the rejection in the post. I have it on good authority that the individual case reviews always take place on Tuesdays. You haven't examined a single case. You explain that to the court.
To be continued.
Is there anyone besides me who has gone through such a story to the final judgement in the highest instance? Get in touch with me, write to me in the blog or on Facebook (click here to go to my public profile: https://www.facebook.com/photo/?fbid=10159518921295808&set=a.49118280807 ) in the comments. I can't be the only one with this problem again.
