Health check (insurance)

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The medical examination (including risk assessment ) is in the personal insurance that of insurers required health certificate of a doctor on the health status of the policyholder or insured person .

General

In the case of personal insurance, the health risk of the insured person is in the foreground, so that the insurer has to assess the probability of an insurance damage through the health check. The health check takes place before the insurance contract is concluded so that the insurer can decide whether or not to insure the health risk ( insurability ). If the insurability is given, he can base the amount of the insurance premium on this. For contracts with a low sum insured only one place survey instead of the insured person, with higher totals (from about 400,000 euros) a medical examination is required.

As early as 1868, the Gothaer life insurance bank developed a special form for medical examinations (health certificate).

Legal issues

Pursuant to Section 19 (1) VVG, the policyholder has an obligation to notify until the conclusion of the insurance contract for the risk circumstances known to him, which are relevant to the decision of the insurer to conclude the insurance contract with the agreed content and which the insurer has asked for in writing . Fraudulent concealment of illnesses makes the contract contestable ( § 22 VVG). The health certificate is one of the obligations of the policyholder ( Section 28 VVG). According to Section 56 (1) VVG, the insurer can terminate the insurance contract and refuse to provide benefits if the duty to notify is violated.

The collection of personal health data by the insurer is permitted in accordance with Section 213 (1) VVG and may only be carried out by doctors, hospitals and other hospitals, nursing homes and carers, other personal insurers and statutory health insurers, as well as professional associations and authorities. It is only permissible if knowledge of the data is necessary for assessing the risk to be insured or the obligation to pay and the person concerned has given consent .

There are certain statutory exceptions to the risk assessment, for example for contracts in the basic tariff ( Section 203 (1) sentence 2 VVG) and in child insurance ( Section 198 VVG). The obligation to contract for the basic tariff does not apply in accordance with Section 193, Paragraph 5, Clause 4 of the Insurance Contract Act if the policyholder violates the pre-contractual obligation to notify under Section 19 of the Insurance Contract Act. The Federal Court of Justice (BGH) decided in July 2016 that no new health check may be carried out when changing tariffs in private health insurance.

Section 18 GenDG sets limits for the insurer when it comes to collecting data from DNA analyzes .

meaning

A risk assessment plays an important role in insurance , especially in the area of personal insurance . The focus is on the health status of the potential customer, under whose knowledge the insurance company assesses whether or under what conditions an insurance contract is concluded. For the insurer, the state of health is relevant because personal insurance insures individual risks, the scope of which depends largely on the health at the time of occurrence.

Data on gender, age, occupation, place of residence, current state of health, information about dangerous sports, etc. are collected. The subjective risk includes the personal behavior of the policyholder, such as the attitude towards illnesses, or the other safeguards that the policyholder takes.

An insurance company is free to reject applications or to accept them only under certain conditions. A contract is only concluded when the policyholder and the insurer agree. This applies accordingly to the Invitatio model , but here the order of the declarations of intent is reversed.

method

Basically there is a health check in the area of private health insurance and in the area of biometric risks such as term life insurance , occupational disability insurance , disability insurance and other insurances in which the health or medical history of the insured person plays a central role in the risk. A health check can also be carried out in combination products.

An insurer generally poses health issues in text form as part of the application formalities. According to Section 19 (1) VVG, the policyholder is obliged to inform the insurer of the risk circumstances known to him, which the insurer has asked about in writing. If information is unclear or incomplete for the insurer, the customer will receive questionnaires from the insurer on the individual pre-existing conditions, which the customer must fill out.

As part of the application formalities or the health check, insurance companies often require a release from the obligation of confidentiality for treating doctors. This enables the insurer to request and check the information directly from the doctor.

The policyholder is responsible for the correctness and completeness of the information. For this reason, applicants should deal with the questions to be expected in advance. It is typical that the health issues cover outpatient therapies for the last 3 years, inpatient treatments for the last 5 years and psychotherapeutic treatments for the last 10 years. However, some insurers also ask for unlimited periods. For example, depending on the question u. a. The following must be stated: mental illness, any information given in the anamnesis (e.g. on questionnaires before surgery), means of self-medication , prophylactic blood tests , diagnoses noted by the doctor on the patient card or in prescriptions , the removal of benign moles, the consumption of cigarettes, alcohol and other drugs, as well as various symptoms (such as headaches, test anxiety, difficulty sleeping and concentrating, sprains, etc.), even if you have not seen a doctor. The policyholder can request an extract from his patient file from a doctor or contact his health insurance company. Treatments that are not covered by the health insurance are also relevant. The patient only has to state the symptoms in general and does not have to use any medical terms. If the applicant fails to mention previous illnesses or other dangerous circumstances, they endanger the insurance cover .

Consequences

Depending on the state of health, the insurer has four options:

  • Acceptance of the application without restriction,
  • Acceptance of the application for a higher premium,
  • Acceptance of the application with an exclusion for certain diseases or
  • Rejection of the entire application.

Incorrect information

If a customer knowingly or unknowingly provides false information, this has consequences for the insurance contract.

  • In principle, in this case the insurer has the right to withdraw from the contract .
  • If false information has not been provided intentionally or with gross negligence , the insurer only has the option of terminating the contract . For this purpose, the legislature gives the insurer a period of one month, the right of withdrawal is excluded in this case.
  • If the information has been made grossly negligent, there is the possibility of continuing the contract under changed conditions. In particular, the insurer can exclude benefits due to a previous illness or demand a premium surcharge.
  • In the event of exclusion or a surcharge of more than 10% of the premium by the insurance company in the context of a breach of the pre-contractual notification obligation (Section 19 Paragraph 4 Insurance Act), the policyholder again has the right to terminate the contract without notice within one month (Section 19 Paragraph 4 Insurance Act) 6 Insurance Contract Act). However, there is no extension of the cancellation period of 14 days if the insurance company would like to accept a normal application from the customer only with exclusions or risk surcharges that increase the premium by more than 10%. This is not a breach of the pre-contractual disclosure requirement.
  • In the event of fraudulent deception, the contract can also be challenged .

Since April 1, 2011, the General Association of the German Insurance Industry (GDV) has been operating the notification and information system (HIS) for the purpose of risk assessment and the clarification of damage cases with suspected manipulation .

See also

literature

  • Wolfgang Wieser: Risk assessment in life insurance , Graz 2008 ( eBook )

Web links

Individual evidence

  1. ↑ Maximilian Koch / Stephan Umann / Martin Weigert (eds.), Lexikon der Lebensversicherung , 2002, p. 51
  2. ↑ Erwin Eszler: Insurability and its limits Hamburg Society for the Promotion of Insurance (Ed.) Issue 21, Karlsruhe, 1999
  3. ↑ Maximilian Koch / Stephan Umann / Martin Weigert (eds.), Lexikon der Lebensversicherung , 2002, p. 75
  4. ↑ Peter Koch, History of Insurance Science in Germany , 1998, p. 178
  5. ↑ Kai-Jochen Neuhaus / Andreas Kloth, Praxis des neue VVG , 2007, p. 49
  6. ↑ Golo Wiemer, The basic tariff in private health insurance , 208, p. 248
  7. ↑ BGH, judgment of July 20, 2016, Az .: IV ZR 45/16 = NJW 2017, 169
  8. ↑ BT-Drs. 16/10532 Draft of a law on genetic examinations in humans (Genetic Diagnostics Act - GenDG ) of October 13, 2008, p. 36
  9. ↑ Health issues with insurance companies. Exact information pays off. In: New Osnabrück Newspaper. 2014, accessed August 11, 2019 .
  10. ↑ Information system of the German insurers - HIS. What it is and what it does ( Memento of the original from January 24, 2016 in the Internet Archive ) Info: The archive link has been inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. GDV, 2015  @1@ 2Template: Webachiv / IABot / www.gdv.de