What is Major Condition 4

Version from 01/01/2008 here

Guidelines
of the Federal Joint Committee
for definition
serious chronic diseases
in the meaning of
§ 62 SGB V

in the version dated 01/01/2005
published in Federal Gazette No. 18 (p. 1343) of January 28, 2004
and from June 29, 2004 (BAnz. No. 115 (p. 13 719)
and from December 31, 2004 (BAnz. No. 249, p. 24 743)

Directive

dated January 22, 2004

§ 1. General

(1) This guideline provides more details on the definition of serious chronic diseases in accordance with Section 62 Paragraph 1 Clause 4 in conjunction with V. m. § 92 Abs. 1 Clause 1 SGB V.

(2) The determination that insured persons are suffering from a serious chronic illness i. S. d. Directive suffering is taken by the health insurance company.

§ 2 Serious chronic illness

(1) A disease i. S. d. Section 62 (1) sentence 2 SGB V is an irregular physical or mental condition that requires treatment. The same applies to illness according to Section 62, Paragraph 1, Clause 4 of SGB V.

(2) A disease is seriously chronic if it has received medical treatment for at least one year, at least once a quarter (continuous treatment) and one of the following characteristics is present:

a) There is a need for care of care level 2 or 3 according to the second chapter of SGB XI.

b) There is a degree of disability (GdB) of at least 60% or a reduction in earning capacity (MdE) of at least 60%, whereby the GdB or the MdE according to the standards of Section 30 Paragraph 1 BVG or Section 56 Paragraph. 2 SGB VII and must at least also be justified by the illness according to sentence 1.

c) Continuous medical care (medical or psychotherapeutic treatment, drug therapy, treatment care, supply of remedies and aids) is required, without which, according to the medical assessment, a life-threatening aggravation, a reduction in life expectancy or a permanent impairment of the quality of life due to the Illness according to sentence 1 caused health disorder is to be expected.

§ 3 receipts

(1) Insured persons provide proof of long-term treatment in accordance with Section 2, Paragraph 2, Clause 1 by means of a medical certificate stating the illness that was treated over the long term. If the need for care of care level 2 or 3 is determined according to the second chapter of SGB XI, after one year since the beginning of the need for care after one of these care levels, the existence of long-term treatment is assumed.

(2) As proof of the degree of disability, the reduced earning capacity and the level of care, insured persons must submit a copy of the corresponding final official notices. The illness for which the insured person is in long-term treatment must be stated in the notification to the GdB or the MdE as a reason.

(3) The existence of the continuous treatment requirement according to § 2 para. 2 letter c is proven by a medical certificate.

(4) Reference can be made to the documents that are already available to the responsible health insurance company.

§ 4 review

The effects of this guideline on the handling of the load limit will be reviewed on December 31, 2004.

§ 5 entry into force

The guideline comes into force on 01/01/2004.