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.
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