German Patients Continue To Have To Sue Insurers/Claim Approvers

Without a doubt, Germany is the largest medical cannabis market in Europe (so far). There have been approximately 100,000 applications so far to the public health insurers. And there are, depending on whose estimate you are using, about 60,000 “legitimate” patients. But again, nobody is sure.

Here is what it is much easier to understand. Patients are still going through huge amounts of paperwork, stress and multiple rejections to obtain government/public health insurer-reimbursed cannabis. So much so that they are still suing (and winning). And further – many of the cases now expected to come to fruition were in fact launched almost immediately after Germany changed the law.

Two and a half years into the “German cannabis experiment” and some of these cases are now seeing their day in court if not the appeals process – which are (no surprise) coming down on the side of the patients who are bringing them.

The latest case to make the news is a Gen X woman, born in 1974. She is both on reduced earning capacity and was prescribed not even bud cannabis but dronabinol by her physician two years ago. Coverage of the same, however, has been repeatedly denied by her insurer in no small part by the botched oversight and review of the regional approver (known as the Medizinische Dienst der Krankenversicherung or MDK). All public health insurers send cannabis prescriptions to the MDK, which is why this case is also so impactful.

Initially, when the patient took the MDK to court, she lost, with a judgement against her this March.

Regardless, on appeal to the Social Court, the plaintiff was found to be within her rights to claim coverage for the drug. Further, the court found that the MDK had grossly misrepresented the plight of the patient and had written four “expert” opinions on the case without accurately describing not only the case, but also ignoring the patient’s and doctor’s rights to prescribe such a drug by focusing on perceived “negative health effects” such as an impact on appetite to dissuade coverage.

In an even more intriguing piece of fallout, the court ruled that the woman’s insurer must not only pay for the cost of the drug for a year but further, must continue to do so if she can prove a positive impact – even before the overall case has finally been decided. Not to do so would violate her basic rights (of being German).

It Still Sounds Like All Greek (if Not German) 

Here is the underlying importance of the case and why this is also likely to further force not only health insurers but all regional MDKs to get a bit more hip on medical cannabis.

1. The first is that a woman who is severely disabled – enough for it to impact her income – has a health condition that clearly fits her eligibility for medical cannabis currently.
2. The second is that her insurer turned her down because of (repeated) badly written coverage reports from the regional approver.
3. The third is that the court has decided that this decision is actually in the hands of the doctor (first) not the MDK – and since the original prescriber had justifiably prescribed the drug, it was not the right of the MDK to try to sidestep the professional opinion of the primary doctor. Nor within the purview of the insurer to rely on the MDK rather than the doctor to try to deny coverage.
4. The precedent set here is also important – namely that the insurer must pay for the drug for a year to determine if it will make a difference – and further on an interim basis while the entire discussion of medical cannabis is being examined by authorities (more generally).

Overall Longer-Term Impact – Good News For Patients

The decision is basically an escalation to the Landessozialgericht (regional social court) from the first interaction with a local one (which has now been overruled) – and further before a final regional ruling has been made. It is significant because this should (as the judges no doubt intended) stop local MDK’s from slowing down the approval of cannabis-related drugs specifically – if all other factors justify the prescription.

Logically, this should also now break a bit of a dam free in prescribing and obtaining approvals for cannabis under German healthcare. Starting with the fact that the regional approvers may not slow down the process of mandating covered payment for a drug originally prescribed (rightly) by the patient’s doctor and further for a rare condition for which no other drug could treat.

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