Cashier not compelled to cover the costs of male breast reduction surgery, court rules
Statutory Health Insurance Denies Coverage for Gynecomastia Treatment in Germany
A man in Germany has had his health insurance refuse to cover the costs for a gynecomastia treatment, despite his appeals to the Social Court Stuttgart and the Baden-Württemberg State Social Court.
Gynecomastia is a condition where men's breasts enlarge to resemble a female breast. This condition can psychologically burden affected men and cause pain. In the case of the unnamed man, he has been suffering from a benign enlargement of the breast glands for years.
The court did not find evidence to support the man's description of severe pain, and his psychological distress does not justify cost coverage for the operation. The court believes there is no disfigurement due to the enlarged breast, and in everyday life, enlarged breasts in obese men are not noticeable.
The man had attempted hormone therapy, but it was unsuccessful. He then applied to his health insurance for cost coverage for a breast reduction. However, the court stated that the subjective assessment of the affected person is not decisive in determining physical abnormality.
The court also found that milder means of treating gynecomastia, such as weight loss and physical activity, are reasonable. No documented work absences, pain therapies, or prescribed pain medication were presented.
The court's decision (Az.: L 11 KR 3239/22) was highlighted by the portal "anwaltauskunft.de". The decision underscores the importance of providing adequate documentation of the patient’s symptoms, including physical pain and psychological distress, to justify that the condition significantly impairs health or quality of life.
If these criteria are not met, insurers may classify gynecomastia treatment as elective or cosmetic and deny coverage. Psychological treatment, such as psychotherapy, should be the primary treatment for the man's psychological distress.
In many healthcare systems, treatment coverage by statutory health insurance often depends on demonstrating medical necessity, which includes exhausting or attempting less invasive interventions prior to surgery or other invasive treatments. The absence of clear evidence documenting pain or psychological suffering, alongside available conservative treatment options, commonly results in rejection of coverage claims.
Therefore, for coverage approval of gynecomastia treatment under statutory health insurance, it is important that milder treatments have been tried without sufficient relief and that the patient’s physical and mental burdens caused by gynecomastia are clearly and adequately documented.
Sports, such as weightlifting or running, could potentially help alleviate some symptoms for individuals suffering from gynecomastia by improving overall health and wellness. However, science reveals that weight loss and physical activity might not be an effective solution for everyone experiencing this medical condition.
In the realm of mens-health, it's crucial to recognize that, while science and health-and-wellness practices can improve certain aspects of life, they may not always provide a definitive solution to complex conditions like gynecomastia. Thus, appropriate medical interventions should be seriously considered and well-documented to ensure statutory health insurance coverage.
