The claimant, A., has been cared for by her mother as a family caregiver since 1 January 2023. However, her health insurance limited reimbursement for care services to those provided from 16 March 2023 onwards, the date on which a needs assessment was available. Upon objection, her health insurance upheld its decision. A’s subsequent appeal to the Glarus Administrative Court was unsuccessful, with the court ruling the health insurer’s duty to pay began only on 27 April 2023, the date of the physician’s order.

The Federal Supreme Court focused exclusively on determining the precise moment at which the insurer’s obligation to cover care services arose. Under the legal framework applicable until 30 June 2024, Swiss compulsory health insurance is required to reimburse care services only if there is both a documented needs assessment and a physician’s order issued prior to the delivery of care. While such an order need not be set out in writing and may, in some cases, be inferred from medical records, a subsequent retroactive approval does not suffice to trigger coverage. The Court emphasised that this prerequisite is of particular importance in situations where care is provided by family members, and clarified that the timing of the physician’s order cannot be considered arbitrary, provided that the physician acts without undue delay upon receipt of the needs assessment. In the case at hand, the Court found no evidence that a valid physician’s order existed before 27 April 2023 and identified no exceptional circumstances warranting an earlier reimbursement obligation. Consequently, payment for care services prior to this date was denied. The appeal was therefore dismissed.

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