New decision: Health insurance company must pay for bathing prosthesis with ankle joint - A rigid prosthetic foot is not enough

According to the law firm Hartmann, Lünen, which specialises in the healthcare market, the LSG Saarland in its judgment of 11.12.2019 (L2 KR 31/18) granted a claimant's claim for the provision of a bathing prosthesis with a movable ankle joint, which is comparable in function and quality to her everyday prosthesis.

As is well known, the entitlement to the provision of assistive devices is regulated by the law of the statutory health insurance, the 5th Social Code (SGB V). According to this, the health insurance fund bears the costs of the provision of medical aids if the requirements of the entitlement (§ 33 SGB V) are met. Since the provision of assistive devices with prostheses is a so-called direct disability compensation, insured persons are entitled to compensation for the functional deficit as far as possible, taking into account the current state of medical and technical progress (BSG judgment of 21.03.2013, B 3 KR 3/12R).

In case law, it has already been recognised that leg amputees are entitled to be provided with a bathing prosthesis; so far, however, only to stay at home in the bath and shower as well as in wet areas such as swimming pools, by the river or lake, so that the everyday prosthesis is not damaged in a wet environment. This had already been confirmed by the Federal Social Court in its judgment of 25.06.2009 (Az. B 3 KR 2/08 R), but not the question of what level of equipment a bathing prosthesis must have. For this reason, health insurance companies have usually only approved a rigid prosthetic foot, which does not allow fluid and safe movement sequences in swimming pools. As a justification, it was often argued that simple equipment with a rigid prosthetic foot was sufficient for showering and moving around in wet areas.

State-of-the-art technology in the sense of being on a par with a healthy person

A insured person who had applied for a bathing prosthesis with a movable ankle joint did not agree with this reasoning and filed a lawsuit. In the proceedings conducted by the law firm Hartmann Rechtsanwälte from Lünen, the sued statutory health insurance company has already been ordered in the first instance and now also in the second instance before the Saarland Regional Social Court to equip the lower leg amputee with a bathing prosthesis with a waterproof Echelon prosthetic foot that has biomimetic ankle joint hydraulics. The court found that a simple fitting, with a "rigid" foot, is not sufficient for the plaintiff's bathing prosthesis. According to the findings of the Court, this prosthesis with a movable Echelon foot for wet use offers the plaintiff significant advantages in use and she is able to adapt her gait pattern to a healthy person to a large extent. In the opinion of the court, natural rolling is not possible with a conventional prosthetic foot without joint hydraulics and leads to unnatural running behaviour. Therefore, the plaintiff could not be referred to a rigid prosthetic foot; such a supply had led to a one-sided limp.

The appeal was not admitted.

Following the example of nature – the Echelon prosthetic foot

A person's ankle and foot are made up of 28 bones and 33 joints, which work together to provide balance, stability and symmetrical walking.