A., insured seeking full home care reimbursement in Switzerland; needs case-specific assessment for home vs institutional care
Walder Wyss Rechtsanwälte | Decision 9C_135/2025 of 23 March 2026
2025 of 23 March 2026
A., born in 1969 and suffering from Down’s syndrome with multiple additional impairments, has been insured under the compulsory health insurance scheme with Mutuel Assurance Maladie Ltd. since 2015 and has received home care services provided by B. LLC since 2017. In April 2023, B. LLC assessed a care need of approximately 180 hours per month. However, Mutuel Assurance Maladie Ltd. limited coverage to 79.5 hours, arguing this was the maximum compatible with the legal criteria of efficacy, appropriateness and cost-effectiveness (Kriterien der Wirksamkeit, Zweckmässigkeit und Wirtschaftlichkeit, WZW criteria). Subsequent assessments confirmed even higher care needs, but the insurer upheld its limitation. The Social Insurance Court of the Canton of Vaud dismissed A.’s appeal on 22 January 2025, after which A. appealed to the Federal Supreme Court, seeking full coverage of home care or, alternatively, a reassessment.
The Federal Supreme Court examined whether the insured was entitled to full reimbursement of home care services under compulsory health insurance in light of the WZW criteria. According to established case law, home care is only cost-effective where it provides a clear advantage over institutional care and where its costs are not grossly disproportionate to those of residential facilities. The Court noted that while home care may be more suitable in certain circumstances, particularly where it enables significant personal, professional or family participation, a marked cost excess generally precludes full reimbursement unless exceptional added value is demonstrated. In the present case, the lower court had relied heavily on precedents involving substantially different factual circumstances without sufficiently considering current medical assessments regarding the suitability of institutional care. The Federal Supreme Court therefore held that a more specific assessment was required to determine whether home care provides a clear advantage over institutionalisation and whether institutional care constitutes an appropriate alternative.