Ruling: No obligation for the cashier to cover the costs of male breast reduction surgery
In a recent decision, a man's appeal for health insurance coverage for a breast reduction operation due to gynecomastia was denied, with both the Stuttgart Social Court and the Baden-Württemberg State Social Court ruling in favour of the insurance company.
Gynecomastia, a condition where men's breasts enlarge to resemble a woman's, can cause psychological burden and physical pain. The breast can feel tight and sensitive to touch, and in this case, the overweight man had been experiencing the condition for years. He reported pain and psychological suffering due to the enlarged breast, but the court did not find sufficient evidence to support his description of severe pain.
The court's decision states that for disfigurement to be considered, a physical abnormality must attract constant attention, causing the person to withdraw and no longer participate in social life. However, the court decided that enlarged breasts in adipose men do not attract attention in everyday life. Consequently, there was no disfigurement from the enlarged breast, as it is commonplace in adipose men.
Statutory health insurance coverage for gynecomastia treatment generally depends on the severity of the condition and whether conservative options such as weight loss and physical activity have been attempted or are likely to be effective. If milder treatment options like lifestyle changes are available and sufficient, insurance often does not cover surgical treatment, as surgery is typically reserved for cases with significant physical disfigurement or medical necessity.
The court suggested that the psychological distress should be treated primarily psychotherapeutically, such as through psychotherapy. The man had previously tried hormone therapy, but it was unsuccessful. After the health insurance refused to cover the costs of the breast reduction, he took his case to court.
The court considered milder means of treating gynecomastia, such as weight loss and physical activity, as reasonable. However, the court reaffirmed its stance that surgery is not necessarily the most appropriate treatment for gynecomastia. The judgment referring to the man's case can be found on the "anwaltauskunft.de" portal (Az.: L 11 KR 3239/22).
In summary, statutory health insurance may cover gynecomastia treatment if conservative treatments fail and if the patient’s disfigurement or medical complications reach a level that qualifies as reconstructive or medically necessary rather than purely cosmetic. The exact criteria and coverage decisions vary by insurance provider and local regulations, so patients are advised to consult their insurer to verify coverage conditions.
Mental health therapies, such as psychotherapy, could be beneficial in addressing the psychological distress caused by gynecomastia in men. The denial of coverage for a breast reduction operation due to gynecomastia highlights the need for insurers to consider men's health, including mental health, in their decision-making process. In terms of health-and-wellness, it's essential to explore a variety of therapies-and-treatments like lifestyle changes, hormone therapy, and surgical intervention when addressing conditions like gynecomastia, which can significantly impact an individual's quality of life.
