Insurance Medicine Bethesda Hospital Basel: Expertise in social and preventive medicine

Medical officers advise insured persons, companies, businesses, health, pension, IV and other insurance companies on specialised issues such as the effectiveness, appropriateness and cost-effectiveness of medical services as well as remuneration, tariff application and the insurance company's obligation to pay benefits. They have a good knowledge of the Health Insurance Act, the Swiss Health Insurance Manual, the Swiss Medical Examiners' Manual and data protection.

Medical officers obtain the necessary information from the service providers, e.g. specialists and general practitioners, such as information from the medical history, medical reports, operation reports and certificates of incapacity for work. They assess these and clarify any open questions in an additional examination. They make a well-founded diagnosis and prepare the insurance companies' decisions on benefits such as pensions, hospital treatment or certain treatment and therapy measures.

The subject of the medical report is not the illness itself, but only its effect on the employee's ability to work and perform.

The employer is not entitled to specific information on diagnoses, medication taken, previous illnesses, etc. However, general comments are permitted if they are necessary for the assessment of work and performance capacity or if the information in question is important for understanding the report.

Medical reports are prepared by physicians, neuropsychologists and carers. The clients are social insurance companies, private insurance companies, authorities, employers and courts as well as private individuals. The aim is to clarify the obligation to pay benefits. medical, neuropsychological and nursing expert reports serve to clarify ambiguous medical facts to such an extent that it is possible to answer the legal questions associated with them. In order to fulfil the rules of evidence of the legal system, the experts must limit themselves in an expert opinion to established medical findings. An assessment is based on objectively verifiable - and therefore also reproducible - findings (reliability). The following are assessed

the natural causality of an illness or accident and the effects of the health impairment on participation and possible activity in everyday functions and in everyday working life are assessed. Medical facts are clarified, plausibilised and put into context so that the associated legal questions can be answered in an adequacy assessment. The questions to be clarified are as follows.

• Statements on the natural causality and unfavourable interrelationships of a health impairment and consistency check with reference to standard indicators of federal court case law
• Consideration of possible damage to integrity and compensation
• Diagnoses with and without an impact on the affected person's ability to work in their usual occupation or in a reassigned job
• Functional capacity and workplace ergonomics measures Proposal for integration adapted to the condition
• Clarification and therapy options

• EFL = evaluation of functional performance
  • Assessment of physical and biomechanical/physical abilities and deficits in relation to work-related activities.
• BAL = Assessment of work-related performance
  • It is primarily designed for insured persons for whom no target agreement is reached within a reasonable period of time as part of an inpatient treatment attempt in the clinic or whose agreed targets cannot be achieved due to a change in behaviour, resulting in treatment being discontinued.
  • The programme focuses on musculoskeletal and neurological areas and is also possible as an isolated service without a prior therapeutic stay.

If necessary, we carry out extended clarifications with our co-operation partners.