Policyholder v. Health Insurer: Reduction Mammoplasty Coverage Dispute

A policyholder appealed a health insurer's refusal to cover the costs of a reduction mammoplasty, arguing that the procedure was medically necessary to alleviate chronic neck and back pain caused by large breasts. The court considered whether the procedure met the legal requirements for cost assumption under mandatory health insurance, which typically requires treatment for illness, not solely aesthetic concerns, and whether the insurer's decision was sufficiently substantiated. The court ultimately upheld the lower instance's decision, reasoning that the evidence did not conclusively demonstrate that the conservative treatments already attempted were ineffective or that the reduction mammoplasty was the only viable option to treat a qualifying medical condition under the relevant insurance regulations.