Krankenversicherung: Lipödem: Private KV muss OP-Kosten nur teilweise erstatten

A lipödem is a chronic fat distribution disorder characterized by excess fatty tissue, primarily affecting the arms and legs. The condition often brings pain, increased sensitivity to pressure, and limited mobility. It can be treated surgically. If liposuction is medically necessary, a private health insurance must reimburse the treatment costs, but it doesn't have to pay the full amount.

This was decided by the Oberlandesgericht Frankfurt am Main on February 13, 2026 (case number 3 U 99/25), according to the legal portal anwaltauskunft.de. The plaintiff suffered from a lipödem and underwent liposuction in a private clinic at the end of April 2021. After the fat was removed, excess skin was also taken from both arms and stretched.

The clinic billed a total of €9,780.93 for the procedures and anesthesia. The private health insurance initially reimbursed €1,344.25. The patient demanded compensation for the remaining costs, but the lower regional court only agreed to a small additional amount, and she appealed. The Oberlandesgericht ruled that both liposuction and subsequent skin tightening were medically necessary treatments.

The insurance company must therefore pay the additional €1,376.86. However, the patient does not have a claim for full reimbursement of the clinic bill, as the criteria of the physicians' fees ordinance are decisive for reimbursement. The court stated that certain services can only be billed to the extent provided therein. Also, particularly high increment factors from the honor agreement between the patient and clinic are not fully reimbursable.

Therefore, parts of the bill were reduced. The decision shows that private health insurance holders must differentiate between the medical necessity of a treatment and its billing, as commented by the German Lawyers' Association. As of July 1, 2026, liposuctions for lipödem, regardless of stage, can be billed as contract physician services under certain conditions including a six-month conservative treatment without adequate relief, diagnosis, weight trend, BMI, and medical qualification. Prior to this, liposuction was only a temporary insurance service for severe lipödem stage III.