In its judgment, the Federal Supreme Court (the Court) partially upheld the cross-appeals by Helsana Versicherungen AG (Helsana) and A. AG against a judgment of the Arbitration Tribunal for Social Insurance Disputes of the Canton of Zurich (the Arbitration Tribunal) dated 20 January 2025, remanding the case for a new decision on the amount to be reimbursed.

Helsana and its predecessor, Progrès Versicherungen AG, had sought reimbursement of CHF 161’063.28 from A. AG, an ophthalmic surgery provider, for compulsory health insurance (OKP) payments for services billed under TARMED position 08.2760 by a physician lacking the required qualitative dignité in ophthalmic surgery. The Arbitration Tribunal had partially upheld the claim, ordering reimbursement of CHF 48’271.60 for services rendered between 16 May 2018 and 19 June 2019. It held that claims relating to earlier services were time-barred under the one-year relative limitation period of former art. 25 para. 2 ATSG, which it considered to have commenced on 1 January 2018, when the national register of university medical professions (“Medizinalberuferegister”) entered into force and became publicly accessible, comparable to the commercial register.

Both parties appealed. The Court confirmed that the physician had lacked the required dignity and that the services had therefore been reimbursed improperly, rejecting A. AG's further objections. However, it held that the Arbitration Tribunal had violated federal law by linking the commencement of the limitation period to the entry into force of the register: under art. 5 para. 2 of the Ordinance on the Register of University Medical Professions and its Annex 2, ophthalmic surgery was not among the qualifications subject to mandatory registration. The register therefore lacked the comprehensive coverage required to give rise to a publicity effect.

Applying the case law on the "second occasion" (“zweiter Anlass”), according to which the limitation period for administrative errors commences when the insurer could reasonably have discovered the error rather than when it was first made, the Court found no such findings in the Arbitration Tribunal had made no relevant findings of fact.

The case was therefore remanded to determine when the insurers should reasonably have become aware of the claim and to reconsider the related arguments concerning timely interruption of the limitation period and the sufficiency of the parties’ pleadings.

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