Hope for insured persons: motion calls for proper medical clarification

Based on the recommendation of the Federal Commission for Quality Assurance in Medical Assessments (FCAQA), the cantonal IV offices have not awarded any more contracts to PMEDA AG since October 2023. The recommendation was made after the EKQMB identified significant deficiencies in PMEDA's IV reports. People who were assessed by PMEDA and whose entitlement to benefits was wholly or partially rejected by the DI subsequently demanded a reassessment of their entitlement to benefits by the DI. The initial euphoria over the success achieved against the PMEDA evaporated when the first sobering Federal Court judgements were handed down.

According to the Federal Supreme Court, no revision can be requested based on the recommendations of the ECQMB in IV proceedings that have already been legally concluded (judgement 8F_1/2024 of 12 December 2024). This does not apply even if the IV decision is based on a questionable PMEDA expert opinion. It is therefore clear that there is currently no entitlement to a reassessment of completed IV proceedings, which means that legally binding benefit decisions remain in place. To date, the EKQMB has only advised against cooperation in the PMEDA case, although other assessment centres have also been heavily criticised in some cases. In these cases too, it is to be feared that reports that are flawed in terms of content and form will be protected by the IV offices, the FSIO and the courts until a recommendation from the EKQMB is available. Even if cooperation with these assessment centres were to be terminated on the basis of the ECQMB's recommendation, there is currently no legal basis for reopening cases that have been legally assessed.

This unsatisfactory situation is now to be remedied at the legislative level. The National Council's Social Security and Health Committee (SGK-N) has analysed the revelations regarding the inadequate expert reports prepared by the PMEDA and passed a motion in January of this year. It calls for an amendment to the Federal Invalidity Insurance Act (IVG) and an amendment to the text of the ordinance (IVV). In future, insured persons should be able to submit a request for a review if a rejected or only partially approved IV benefit decision is based on a medical report from an institution or doctors with whom cooperation was discontinued on the basis of a recommendation from the EKQMB. On receipt of an application for revision based on this new provision, the IV centres are to reassess the ability to work and award any pension benefits retroactively. The Commission emphasises: "Decisions on the granting of disability insurance (IV) benefits must be based on high-quality medical reports. Trust in disability insurance depends on this." (see press release dated 17.01.2025).

In its statement on the motion, the Federal Council states that it is absolutely crucial that IV offices and courts rely on correctly prepared and high-quality medical reports. With regard to the required legal regulation, it refers to the upcoming IV revision. There, the matter will be examined from the point of view of the prohibition of retroactive effect of laws.

The initiative is to be welcomed from the point of view of insured persons for various reasons. Whether an IV benefit is granted or not has a major impact on the financial situation of those affected. This is also because the IV's decision often leads the way and other insurers follow suit. This applies in particular to benefits from the 2nd pillar. Decisions made by the IV office are generally binding for the pension fund. In addition, the most recent rulings of the Federal Supreme Court on procedural revision (e.g. ruling 8F_1/2024 of 12 December 2024 with further references) have shown that the problem must be solved at a legal level.

The Grand Chamber approved its committee's motion by 128 votes to 63 with one abstention, thereby referring the matter to the Council of States.