In its judgment, the Federal Supreme Court (the Court) dismissed an insured person’s appeal against a judgment of the Social Insurance Court of the Cantonal Court of the Canton of Vaud (Cour des assurances sociales du Tribunal cantonal du canton de Vaud) of 6 November 2023. At issue was the number of chiropractic sessions to be covered by compulsory health insurance.

The insured person had received chiropractic treatment two to three times a week for chronic neck and shoulder pain since 2007. Her health insurer had limited coverage to 36 sessions per year. The Cantonal Court partially upheld her appeal but likewise limited coverage to 36 sessions per year for the period from 27 August 2010 to 31 December 2017. Before the Court, the insured person sought coverage of all sessions.

The Court recalled that services provided by physicians and chiropractors were presumed to meet the criteria of efficacy, appropriateness, and cost-effectiveness under art. 32 para. 1 of the Health Insurance Act (Bundesgesetz über die Krankenversicherung, KVG). A health insurer could rebut this presumption in an individual case, for example on the basis of an expert opinion.

The Court held that the Cantonal Court had not acted arbitrarily. The insured person suffered from a persistent somatoform pain disorder, which entailed a risk of therapeutic dependence. Despite the high frequency of sessions over several years, no proportionate objective improvement had been shown. Her subjective need for treatment and the stability of the therapeutic relationship did not justify such intensity. The more frequent and prolonged a treatment was, the more convincing its justification had to be. The absence of a scientific maximum number of sessions did not create a right to virtually unlimited treatment.

The limit of 36 sessions per year was based on a sufficiently reasoned court-ordered expert opinion and on art. 32 KVG, read in light of the principle of cost-effectiveness under art. 56 KVG. The Court therefore left open whether the physiotherapy rules applied by analogy to chiropractic treatment.

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