Oldenburg Social Court, 05.09.2011, Ref.: S 61 KR 151/11
The circumstances that trigger compulsory insurance in the statutory health insurance scheme are listed in Section 5 SGB V. The group of compulsorily insured persons includes, among others, workers, employees or students as well as recipients of certain social benefits.
People who have no other entitlement to insurance in the event of illness are also compulsorily insured in accordance with § 5 SGB V.
For those subject to compulsory insurance, membership begins on the day on which the requirements for compulsory insurance are met, § 186 SGB V.
In the case of workers, employees or trainees, this is the day on which they enter employment subject to compulsory insurance.
In the case of voluntary membership of statutory health insurance pursuant to § 9 SGB V, membership pursuant to § 188 para. 1, 3 SGB V generally begins on the date of joining, i.e. the date of written registration with the health insurance fund.
If the previously compulsorily insured person wishes to continue to be insured voluntarily in the statutory health insurance scheme because the compulsory insurance has ceased for any reason (so-called continued insurance), voluntary membership in accordance with § 188 Para. 2 SGB V immediately follows the end of the previous compulsory insurance.
This means that the obligation to pay contributions (§§ 223 Para. 1, 240 SGB V) also begins immediately. This prevents those entitled to insurance from utilising the three-month declaration period of § 9 Para. 2 SGB V until the end solely in order to save contributions.
It often happens that statutory health insurance companies refuse to insure certain people.
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In the case mentioned above, the Oldenburg Social Court had to decide whether the plaintiff was compulsorily insured under the statutory health insurance scheme or whether the plaintiff should have received health assistance as part of her receipt of SGB XII.
Case Background
The claimant, who was born in 1959, received basic income support in old age and in the event of reduced earning capacity in accordance with SGB XII. As she was no longer able to manage her own affairs, a legal guardian was appointed for her, who was responsible for health and legal matters, among other things. The city of E had previously also assumed the plaintiff's treatment costs as part of the health assistance programme. From 1 November 2010, the plaintiff's parents agreed to cover her living expenses, as a result of which the City of E discontinued the social welfare benefits. The plaintiff then applied for admission to the statutory health insurance scheme.
Application for admission to statutory health insurance
After the claimant's parents had to discontinue their support due to financial difficulties, the claimant again applied for basic income support, which was granted to her from 1 December 2010. However, the health insurance fund rejected the claimant's application for inclusion in the statutory health insurance scheme, arguing that the interruption in the claimant's receipt of basic social security benefits had been too short to justify compulsory insurance in accordance with § 5 Para. 1 No. 13 SGB V. The defendant saw this as an attempt to circumvent the social welfare provider's obligation to provide benefits.
Decision of the Oldenburg Social Court
The Oldenburg Social Court agreed with the plaintiff and ruled that the health insurance fund was obliged to accept her into the statutory health insurance scheme. According to § 5 Para. 1 No. 13 SGB V, persons who have no other entitlement to cover in the event of illness and were last covered by statutory insurance are subject to compulsory insurance. As the claimant was covered by basic income support and health assistance before November 2010 and this cover ceased to apply from 1 November 2010, she was compulsorily insured. This also applied to long-term care insurance in accordance with § 20 Para. 1 SGB XI.
Exclusions and judgement
The exclusion criteria of § 5 Para. 8a SGB V, according to which an interruption in social assistance of less than one month excludes the obligation to take out insurance, did not apply to the plaintiff, as the interruption lasted exactly one month. The court emphasised that, according to the clear wording of the law, the obligation to take out insurance arises in the event of an interruption of at least one month. The court did not consider a broader interpretation, which could lead to a rejection of the insurance obligation, to be necessary. The defendant was therefore obliged to include the plaintiff in the statutory health and long-term care insurance scheme.
Source: Social Court Oldenburg
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