New Ruling by the Berlin Social Court on Reimbursement for Inpatient TB Treatment
Statement from the DZK and our Expert Advisory Board, Dr. N. Schönfeld:
In a dispute between a Berlin hospital operator and a statutory health insurance provider, the Berlin Social Court has handed down a potentially landmark ruling.
In the case of a breastfeeding mother (2017) diagnosed with cavernous—and therefore contagious—pulmonary tuberculosis, the insurance provider initiated a review pursuant to Section 275 of SGB V to determine whether there had been an inappropriate admission or whether the inpatient treatment (49 days) had been provided solely for the purpose of isolation. The Medical Service’s expert concluded that the necessity of inpatient treatment was not medically justified (“The necessity and duration are not medically justified. The diagnosis and treatment of tuberculosis can be performed on an outpatient basis. There were no relevant impairments or symptoms. The treatment proceeded without complications, except for a brief asymptomatic elevation in liver enzyme levels. Strict isolation was not enforced; the patient was free to move about the hospital grounds.”) Based on this expert opinion, the health insurance provider refused to pay.
Consequently, the hospital operator successfully filed a lawsuit with the Berlin Social Court (S 71 KR 2520/22, Berlin Social Court). The defendant was ordered to pay the full amount for the entire course of treatment. The judgment of March 5, 2026, was based on an expert opinion prepared by a pulmonologist holding a senior position at the hospital. Reasons: “The expert, who possesses highly specialized knowledge and many years of relevant experience, and whose statements were coherent and comprehensible, confirmed during his testimony that massive open tuberculosis in a breastfeeding mother who was clearly symptomatic is a serious illness that cannot be adequately treated on an outpatient basis. He also explained that it is characteristic of the typical course of severe active tuberculosis for the affected patient to assess her own condition as less impaired and weakened than it actually is. It is characteristic of the course of the disease that patients only realize retrospectively—once the burden of the illness has largely subsided—how severely their health had been compromised. Accordingly, while the Chamber included the findings in the patient records in its legal review, it assigned them only a weight that was modified based on the expert’s explanations when considering the case as a whole.”
However, in this context, that means the judge fully recognized the equivalence of infectiousness and overall severity of the illness as a decisive basis for inpatient hospital treatment.
To the best of our knowledge, this is the first time a court ruling has been issued nationwide with such clarity; typically, such cases have resulted in settlements up to this point.
It seems conceivable that this reasoning in the judgment could be helpful in justifying inpatient treatment for a patient with active tuberculosis beyond the indications specified in the S2k guideline, both in out-of-court and court disputes.
