I 2023 32 — Insurer Internal Guideline Cannot Restrict Contractual Coverage

A claimant sought reimbursement from a supplementary health insurance policy for costs associated with a hospital stay and treatment, expenses which were incurred after the insurer had denied coverage based on an internal guideline that restricted coverage for certain treatment methods unless specifically listed as covered benefits in the general policy conditions. The court ruled that the insurer's internal guideline could not unilaterally restrict the scope of benefits agreed upon in the general insurance conditions, as the insurer failed to prove that the claimant was explicitly aware of and accepted this narrower interpretation during the contract formation, thus upholding the claimant's right to reimbursement for the treatment costs.