Rechtliche Implikationen der Stratifizierung des Versichertenklientels nach § 25b SGB V – Anforderungen an Patienteninformation und KI-Einsatz

Statutory health and long-term care insurance may analyse insurance data. The data analysis can result in various information obligations. Firstly, they exist when a specific health risk to the insured person is recognised. This presupposes that there is a sufficient probability of damage to health. They must also provide information if they recognise through their data analysis that there is a foreseeable future possibility (not probability) of illness or a need for long-term care arising from the individual (life) circumstances of a single insured person. Whether these thresholds are reached in each case is ultimately determined by medical science and healthcare research. Statutory health and long-term care insurance must always be able to justify in a comprehensible manner how they arrived at their results and why they made which information decision. These legal requirements limit the use of artificial intelligence insofar and as long as it cannot make its procedures and results transparent and comprehensible. Violations of these requirements can result in claims for information and damages against the health and care insurance funds