Dianne Vugts wants to keep practising sports after the amputation of her leg. However, the insurance company of the 49-year-old does not want to cover this. According to Dianne, the system should change. Therefore, she takes her insurance company Interpolis to court. Martin Buijsen, Professor of Health Law at Erasmus School of Law, understands both Dianne's and Interpolis' positions, which he explains to RTL Nieuws.
Interpolis declined Dianne's request for a sports prosthesis for running because she already owns a prosthesis for daily use. For practising sports, she needs another unique prosthesis. Dianne's rehabilitation doctor drew up an 'operational indication statement' in which he labelled the sports prosthesis as functional. The insurance company, however, denied the request without contacting Dianne or her rehabilitation doctor.
This way of insurance practice is not an exception. Buijsen explains that medicinal and aid products must be functional for being eligible for compensation through the basic insurance policy. "A prosthesis for daily use is always covered. You need it to go through daily life properly", explains Buijsen. "A prosthesis for sports is, according to the law, no medical necessity. That is why insurance companies can legally deny those claims."
A part of the sports prosthesis can be financed through the law for societal support (WMO) and the platform Uniek Sporten of the Disabled Sports fund. Dianne does not want to use this fund since she considers prosthesis part of the insurance companies' duty of care.
Nike Boor, director of the Disabled Sports fund, supports Dianne's lawsuit. He explains that his fund is a stopgap solution and a desirable structural solution. The ideal solution, however, is compulsory coverage of sports prostheses from the basic insurance policy. In addition, he mentions that insurance companies harm their interests. "The Kenniscentrum Sport en Bewegen has calculated that an investment in sports prostheses has a payout of around 4,5 times", explains Boor. "Because of sports prostheses, people stay healthy, fit and positive. Therefore, people rarely need other types of care."
Buijsen understands the insurance companies: "I comprehend that insurance companies do not cover a sports prosthesis. Calling it ‘luxury’ is not correct, but it is not necessary for living a normal life", explains the professor. "The law has to draw a line somewhere, because the money comes from collective resources." Buijsen also stresses that he understands the arguments of Dianne and Boor: "It is true that these people need less additional medical care. They both make a good point. In the end, the government has made this choice." Buijsen concludes that insurers do not do anything wrong when denying these claims. "On the other hand: nothing stops them from covering these prostheses."