Private health insurance

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Private health insurance companies ( PKV for short ) are private-sector companies that offer health insurance . The insurance relationship is different from the statutory health insurance not by law but by private law agreement concluded. Despite legal and organizational differences to the statutory health insurers , private health insurers are colloquially called private health insurers .

In the German health system , private health insurance is possible both in addition to or instead of statutory health insurance (GKV) (two-tier or dual health insurance system). With 8.77 million in 2016, around 11 percent of all insured persons in Germany had full private health insurance; there were also another 25 million additional insurances.

On January 1, 2009, with the SHI Competition Enhancement Act , a compulsory insurance introduced in the private health insurance not otherwise hedged persons ( § 193 para. 3 SGA ).

Private health insurers in Germany

Corporate forms

Private health insurance is operated by private insurers in the form of joint-stock companies (currently 24 companies) and mutual insurance associations (currently 19 companies). Their legal basis is formed by company law , Section 193 of the Insurance Contract Act and the Insurance Supervision Act . In the PKV, health insurance comes about through a contract under private law, on which the designation private health insurance is based. A voluntary legal relationship arises, which includes the obligation for the policyholder to pay the agreed contributions as well as the right to contractual benefits if the insured event occurs . All PKV insurers based in Germany are subject to the legal and financial supervision of the Federal Financial Supervisory Authority . (The providers of statutory health insurance, on the other hand, are exclusively public corporations that are subject to state legal supervision by the Federal Social Security Office or by the state-specific supervisory authorities.) The terms private health insurers and private health insurance themselves are an umbrella term for the entirety of insurers who offer private health insurance.

Largest private health insurer based on the number of fully insured persons

Below are the ten largest German private health insurances according to the number of fully insured persons in 2018 (sources: company reports):

rank
 Companies
 Fully insured persons 2018
 Change to 2000
 Full insurance contributions in billion euros 2018
1 Debeka 2,397,740 + 481.926 4,941
2 Axa 795.005 + 337,521 2,451
3 German health insurance 757.692 - 99,078 3.229
4th Signal Iduna a 621.411 + 105,283 2.862
5 Allianz private health insurance 601.016 - 307.060 2,445
6th HUK Coburg health insurance 415.705 + 198,657 1.536
7th Continentale health insurance 404.339 + 33,688 1.188
8th Bavarian public health insurance fund 321,623 - 95,498 0.964
9 Central health insurance 314,414 - 71,181 1.328
10 Barmenia 298,894 - 9,331 1.228
a Signal Iduna consolidated from Signal Health Insurance a. G. and Deutscher Ring Krankenversicherungsverein a. G.

Advocacy

The general interests of private health insurance and private long-term care insurance are covered by the Association of Private Health Insurance. V. represented. The private health insurance association is the first point of contact for social and regulatory issues; it takes part in parliamentary hearings and introduces the private health insurance positions into national and European legislation. He advises on fundamental questions of tariff structuring and the introduction of new tariffs. The health care of the Federal Railroad officials and the Postbeamtenkrankenkasse as corporations under public law are social institutions of the respective insurers and belong to the PKV Association as affiliated institutions. The private health insurance association is based in Cologne and Berlin.

Scientific Institute of PKV (WIP)

The WIP is the scientific institute for private health insurance. It was founded in 2005 by the PKV Association and is based in Cologne. The WIP studies deal primarily with questions of financing in the health care system as well as with health services research.

Types of health insurance

A distinction can be made according to the scope of private health insurance:

The protection of groups of people entitled to aid, such as civil servants, is also considered to be full insurance.

Private full health insurance

In 2017, around 8.75 million people or almost 11 percent of the population in Germany had private comprehensive health insurance and spent around 39 billion euros on this. For comparison: in 2011, almost 8.98 million people had private comprehensive health insurance (the highest level since private health insurance was established). While the numbers rose steadily almost every year until 2011, they continued to decrease after 2011.

Private supplementary health insurance

In 2017 there were around 25.52 million private supplementary health insurances in Germany (in 2002 there were only 14.2 million, in 2007 around 20 million). While additional dental insurance , additional outpatient tariffs (e.g. allowances for medication, glasses, hearing aids, preventive examinations) and optional inpatient services (e.g. accommodation in a single or double room or free choice of doctor in the hospital) can be chosen specifically in addition to statutory health insurance coverage, are international health insurance , hospital cash insurance and care supplementary insurance by the insured groups of both extent claimed. On the other hand, private daily sickness allowance insurance (for loss of earnings in the event of illness, already included in limited form in statutory health insurance coverage) is mostly taken out by fully privately insured persons.

At just under 15.6 million, the dental tariffs made up the largest share of supplementary insurance in 2017. In addition, there were around 8 million insurances for tariffs in the outpatient sector and around 6.1 million insurances for optional tariffs in hospitals. In addition, there were 7.7 million daily hospital allowance insurances, 3.6 million daily sickness allowance insurances and 2.7 million (unsubsidized) supplementary care insurances. Especially in the care supplementary high growth can be seen: in 2017 there were a total already more than 3.5 million contracts, of which 834,000 state-subsidized supplementary care ( " care-Bahr ").

Additional insurance 2017 (in millions) Insured
Tooth addition 15.56 predominantly those with statutory health insurance
Outpatient 8.02 predominantly those with statutory health insurance
Optional hospital services 6.11 legally and privately insured
Daily hospital allowance 7.74 legally and privately insured
Daily sickness allowance 3.61 legally and privately insured
Care additive unsubsidized 2.73 legally and privately insured
Nursing supplement promoted 0.83 legally and privately insured

membership

Acceptance requirements

A private full health insurance is possible for all persons who are not compulsorily insured in the statutory health insurance according to § 5 SGB ​​V. These are usually:

As with other types of insurance, the basis for concluding a contract with a private health insurer is the individual risk . For private health insurance, in contrast to statutory health insurance , it is usually not the respective gross income that is decisive, but rather the age and state of health before the start of the contract, the occupational group and the benefit to be insured. Since December 21, 2012, only so-called “unisex tariffs” may be offered in Germany, and since then no differentiation has been made according to gender.

In the case of certain health risks or existing illnesses, a risk surcharge or an exclusion of benefits can be agreed upon at the start of the contract. This does not apply to the basic tariff for which there is an entitlement to admission . In the event of a poor financial situation, the insurance company can reject the insurance application. B. with negative Schufa.

Those entitled to benefits for the first time (civil servants on revocation, probationary and lifetime) can also take out insurance with participating private health insurers regardless of previous illnesses (including disabilities) and with a risk surcharge of a maximum of 30 percent as part of the so-called "opening campaign" .

As an alternative to a full private health insurance have compulsory insurance in the statutory health insurance the opportunity to supplement their private legal insurance coverage supplementary complete ( dental insurance , nursing insurance , travel health insurance , inpatient health insurance , etc.). Sometimes there are option tariffs with which i. A. no entitlement to insurance benefits is acquired, but it is ensured that in the event of a later entry into the private health insurance scheme, no further health examination is necessary.

Return to statutory health insurance

In accordance with the law currently in force, the GKV will accept people who were previously insured with private health insurance if

  • these become subject to compulsory insurance (for example as an employee by falling below the compulsory insurance limit or due to unemployment (ALG I), for children at the beginning of a degree or company vocational training), regulated in § 5 SGB ​​V
  • family insurance is possible according to § 10 SGB ​​V

and are under 55 years of age or do not meet the requirement that ( Section 6 (3a) SGB V)

  • they were not legally insured in the five years prior to the commencement of compulsory insurance and
  • at least half of the time (30 months) were exempt from insurance, exempted or not subject to insurance due to self-employment.

The termination of the PKV is only effective - even when switching to the GKV - if the insured person submits a supplementary insurance certificate to the PKV within two months of the notice of termination ( Section 205 (6) VVG).

If a privately insured person receives z. B. after the end of a degree or after giving up self-employment directly unemployment benefit II (Hartz IV), the private health insurance protection remains in place ( Section 5 (5a) SGB V). However, if there is a need for assistance in the sense of SGB II or SGB XII, the social benefit provider responsible will only pay the contribution to an insurance in the basic tariff .

People who - apart from employment before or during their vocational training - take up employment in Germany for the first time, but are therefore exempt from insurance due to an annual salary exceeding the compulsory insurance limit , can voluntarily take out statutory health insurance as a career starter ( Section 9 (3) SGB V). As a result, employees and workers have the chance of GKV membership at least once in their working life, regardless of the level of their income, even if they were previously insured with private health insurance. In this case, the statutory health insurance company must be notified of membership within three months of commencing employment.

Children in private health insurance

Depending on the insurance status of the parents, children can be privately insured or included in the GKV through family insurance.

If the parent with the higher income is insured in the private health insurance scheme, the parents are married to each other and their total monthly income is regularly above one twelfth of the annual wage limit and above the member's total income, no free family insurance is possible in the statutory health insurance scheme ( Section 10 (3) SGB V). There is then a choice between voluntary insurance in the GKV ( Section 9 (1) No. 2 SGB V) and insurance in the PKV.

In the PKV, a separate contribution has to be paid for each child, as there is no free co-insurance for family members. Privately insured parents do not necessarily have to insure their child with the same provider as they do, because some companies also insure children alone. If parents, however, are already insured for at least three months at their company and assure the child later than two months after the birth of the same company that is Kindernachversicherung without the usual medical examination (possible § 198 1 para. ICA). The birth of a child is equivalent to adoption if the child is still a minor at the time of the adoption, however, a risk surcharge of up to 100 percent of the premium can be requested in the case of adoption ( Section 198 (2) VVG).

No aging provisions are made for children. Since no provisions can be lost in this way, it is easier to change providers than with adults.

The parents' entitlement to allowance also extends to one or more children. For employees and their children, the contribution to private health insurance according to Section 257 (2) SGB V subsidized by the employer. The employer pays half of the insurance premium, but not more than the maximum employer's contribution for a statutory insured employee (2019: 351.66 euros).

The co-insurance of children in long-term care insurance is regulated in accordance with the provisions on family insurance in the GKV ( Section 25 SGB ​​XI).

Contract design and types of tariffs

This article or the following section is not adequately provided with supporting documents ( e.g. individual evidence ). Information without sufficient evidence could be removed soon. Please help Wikipedia by researching the information and including good evidence.

According to § 192 Abs. 1 VVG, the private health insurance pays to the agreed extent, i. H. Depending on the tariff, for medically necessary treatment and other agreed services as well as for outpatient preventive examinations for the early detection of diseases according to legally introduced programs. Those insured with private health insurance have a lifelong, legally secured guarantee of the insurance cover once they have taken out, provided they meet their payment obligations.

If necessary, the policyholder can combine different tariff components individually, and z. B. combine different outpatient, dental and inpatient tariffs with one another with modular tariffs. With so-called compact tariffs, outpatient, dental and inpatient services are agreed as fixed insurance benefits. Some tariffs also include a deductible , which means that the insurance only covers the costs if the annual or monthly doctor and medication costs exceed the deductible. Deductibles based on the type of service are also possible (e.g. 10 percent of the drug costs or 15 percent of the therapeutic costs). Upper limits can also be agreed for certain services (for example glasses up to a maximum of 300 euros or orthopedic shoes up to 200 euros). For these tariffs, the insurance premium is lower or part of the premiums is reimbursed if benefits have not been used. In addition, the policyholder can choose between open and closed catalogs of medicinal products . Some services such as cures are excluded.

In the event of temporary payment difficulties, the insurance company can often defer it. If you are overburdened for a longer period of time, you may want to change your tariff , set a higher deductible or cancel unnecessary benefits. In the event of a longer contribution default , the insurer can convert the insured person to the emergency tariff and (like any other creditor) sue for the debts and initiate enforcement measures. In the case of those in need of financial assistance within the meaning of social law , the basic rate contribution is reduced by half, additional costs may be borne by the social assistance provider.

Uniform tariffs across the industry

Base tariff

The amount of the contribution to the basic tariff is limited to the maximum contribution of the GKV in accordance with Section 152 (3) VAG. This is the result of multiplying the general contribution rate by the applicable contribution assessment ceiling in statutory health insurance, plus the average additional contribution in accordance with Section 242a (2) SGB V. The maximum contribution in 2014 is EUR 627.75 (EUR 4,050.00 × 15.5 % plus 0 euros). The individual contribution to the basic tariff can, however, be lower than the maximum contribution, depending on the insurer. If an insured person can prove that the health insurance contribution to be paid results in a need for assistance in accordance with Section 152 (4) VAG, the contribution is halved. For recipients of benefits according to SGB II ( unemployment benefit II , social benefit ) or SGB XII ( social assistance ), the contribution is also reduced by half and paid by the basic social security providers.

Standard tariff

The standard tariff is aimed at older insured persons who, for financial reasons, need a particularly inexpensive tariff. On the one hand, the insured persons can often no longer pay the increasingly higher contributions of the private health insurance as they get older, on the other hand it is then no longer possible to switch to the statutory health insurance. That is why the standard tariff is only open to certain groups of people defined by law. The contribution may not be higher than the current maximum rate of the statutory health insurance. The services are then similar to the services in the statutory health insurance. When changing from the higher-quality tariff to the standard tariff, the aging provisions from the previous tariff are taken over. Depending on the length of the previous insurance period, the contribution can be cheaper than the maximum contribution from the statutory health insurance fund.

The standard tariff is available to the following people, provided they signed their contract before January 1, 2009 and meet the following conditions:

  • from the age of 65 with at least 10 years of full insurance in the private health insurance;
  • from the age of 55 with at least 10 years of full insurance in the private health insurance system and an income below the current compulsory insurance limit;
  • People who have to take early retirement or retirement due to disability. Your income must be below the current compulsory insurance limit and you must have been insured in private health insurance or according to subsidy tariffs for 10 years .

The insurance contracts in the standard tariff concluded up to December 31, 2008 by persons without insurance cover were converted to contracts in the basic tariff on January 1, 2009 ( Section 315 (4) SGB V). Only those insured who had private health insurance at normal rates up to December 31, 2008 enjoy grandfathering and can still switch to the standard rate in the future. It is no longer accessible to new customers.

Unlike the basic tariff, the standard tariff cannot be supplemented with additional insurance.

Emergency tariff

With the entry into force of the law on the elimination of excessive social demands in the case of premium debts in health insurance on August 1, 2013, the emergency tariff (also non- payer tariff) will be introduced for private health insurance ( § 153 Insurance Supervision Act (VAG) ).

Delinquent private health insurance policyholders have not been reclassified to the comparatively expensive basic tariff since then , but instead transferred to the emergency tariff with the help of a dunning procedure ( Section 193 (6) to (10) VVG). The regular insurance contract is suspended during this time. The monthly fee is between 100 and 125 euros. The aim of the low premium is to enable the insured to reduce their accumulated premium debts while they are insured under the emergency tariff. When all debts have been paid off, the insured person returns to his old tariff.

In the emergency tariff, insured persons are entitled to medical services for painful conditions and acute illnesses. Pregnant and younger mothers can claim additional benefits, children and young people have the right to medical check-ups, early diagnosis and vaccinations. Retirement reserves are not created in the emergency tariff. At the same time, however, those affected can use all previous retirement provisions to reduce the premium in the emergency tariff by up to 25 percent.

financing

Contribution calculation

In contrast to the statutory health insurance (GKV), the private health insurance levies insurance premiums that are independent of income . The equivalence principle is decisive for the calculation of the insurance premiums in the PKV . In contrast to GKV, in which the contributions are income-dependent, there is a connection between performance and consideration in PKV. Provisions for aging are set up in accordance with the principle of capital coverage . In the PKV, the insured person is himself a contractual partner of the health professional, the hospital, pharmacies or laboratories. In principle, the reimbursement principle applies , that is, he receives an invoice for all the services he uses.

The contributions of the insured in the private health insurance are calculated according to age, state of health and the desired insurance benefits. Until December 21, 2012, gender was also a basis for calculation. Since then, unisex tariffs have been in effect .

The initial contribution is based on the following criteria:

  • Entry age of the insured person.
  • Occupational group  - For example, the risk for members of the public service is lower and the contribution is correspondingly cheaper, some occupations require higher contributions due to higher risks (dangerous occupations).
  • Tariff benefits  - higher benefits ( e.g. head physician treatment) result in a higher contribution.
  • State of health  - Corresponding previous illnesses lead to:
    • Risk surcharges are usually percentage surcharges on top of the normal premium . Under certain circumstances - but only at the request of the policyholder - depending on the state of health, these can be checked and reduced if necessary.
    • Exclusions from benefits exclude treatment costs for diagnosing a specific pre-existing condition.
    • Rejection  - in contrast to the statutory health insurance, private health insurers can reject an applicant entirely due to their state of health (an exception is the reinsurance of a newborn ). If one parent has been fully insured for at least three months, the newborn must be accepted by the insurer within two months of the 1st month of birth, regardless of their state of health, without risk surcharges or exclusions from benefits ( mandatory contract ). This also applies in a similar form to adoption; however, a risk surcharge of up to 100 percent can be levied here.

The calculation of the contributions (premiums) in private health insurance is regulated in the Calculation Ordinance (KalV). They are discounted to the present day on the basis of the head damage profiles at the time the contributions were determined using the present value method. Characterized an average contribution is determined, which at the time of the statistical life expectancy is constant on the condition that the calculation of the assumptions actually arrive ( ceteris paribus -adoption). Private health insurance, for example, uses part of the contribution to make provisions for rising health costs in old age. Depending on the entry age, state of health and the agreed scope of benefits, the contribution for the entire term (lifelong) is calculated in advance. In the first few years of membership in a private health insurance company, this means that contributions are paid that are higher than the purely medical costs necessary to maintain the insurance business. Interest is paid on these as aging provisions in the form of investments . The investment income generated via the actuarial interest rate ( § 4 KalV) of 3.5 percent is referred to as excess interest and at least 90 percent must be credited to the insurance collective.

Changes in the contribution amount

Due to the reserves formed in the private health insurance and the excess interest on the aging provisions (see above), the private health insurance has income that does not result from contributions. If the assumptions about the provisions to be set up are correct, the contributions remain stable. If the assumptions deviate from the costs, interest, additions and disposals actually incurred in the insurance collective, the premium will change. A premium increase in the private health insurance triggers a special right of termination, which, however, has been restricted by the general health insurance obligation since 2009. If the insured cannot prove any follow-up insurance, termination will have no effect. The following factors are decisive according to § 155 VAG:

  • general increase in costs
  • medical progress , see medicalization thesis
  • increased cost burden within a tariff
  • Change in interest rates and capital market income
  • legal interference in the calculation of premiums for private health insurance
  • Change in the rules of departure (withdrawal from the community of insured persons, through termination or death)
  • Change in the cancellation rate (churn)

In 2007, an independent commission of experts on behalf of the Federal Government came to the conclusion that the aging coverage reserves had tended to be underestimated due to the increasing life expectancy and the expansion of medical options. Therefore the contributions have increased.

Surveys within the framework of the socio-economic panel of the German Institute for Economic Research (DIW) and the journal Finanztest showed , independently of each other, an average increase in premiums for private health insurance of 3.8% to 4.0% per year adjusted for inflation in the period from 1985 to 2005 firmly. In this context, the DIW concludes that the premiums of private health insurers have increased almost twice as much compared to the contributions made by statutory health insurers during this period. When looking at the absolute premiums, according to the FAZ, these have more than tripled between 1985 and 2005, although the average premium that a customer transfers to his private insurance company is still well below the health insurance contribution of comparable voluntarily insured persons with statutory health insurance.

According to a study that was commissioned by the Federal Ministry of Economics and prepared by the IGES Institute, the expenditure on benefits per insured person with private health insurance rose by 49 percent between 1997 and 2008. The German Actuarial Association , however, maintains that the reductions in benefits in the statutory health insurance, the federal subsidies to the statutory health insurance and the statutory increase in the contributions in the private health insurance by a 10 percent provision surcharge were not taken into account in this calculation. If these effects are included in the comparison, there is an almost comparable annual premium increase in private health and statutory health insurance of around 3 percent.

Aging provisions

Every contribution to private health insurance also includes the statutory aging provisions . These are intended to counteract higher contributions in old age. In addition, an additional voluntary contribution can often be paid to reduce contributions in old age (the latter is not attractive for many insured persons, since these contributions cannot currently be reclaimed in the event of termination). A rule of thumb is that you should save enough so that two thirds of the contributions can be financed for 25 years in old age. Otherwise, a reduction in benefits or an increase in the excess can be considered. In some societies, it is difficult to lower the deductible again later.

In 2017, old-age provisions reached a value of 247.21 billion euros, in health insurance 212.72 billion euros and in long-term care insurance 34.48 billion euros. The PKV itself sees aging provisions based on the principle of funded coverage as an essential feature of intergenerational equity , because each generation provides for the rising health expenditures of the future and also as an answer to the “demographic problem” of the pay-as-you-go GKV.

According to Section 204 VVG, insured persons have the option of having the aging provisions fully credited with the same insurer when changing tariffs. If the contract is terminated and a change is made to another insurer, the aging provision can be partially transferred . Only those parts of the contract that correspond to the services in the basic tariff are transferable.

Premium refund

The reimbursement of premiums is the partial reimbursement of monthly premiums already paid for full health insurance and supplementary insurance. It is granted if the insured person has not used any benefits for a certain period of time, depending on the insurance provider.

There are currently three different systems:

  • Success-based premium reimbursement - This is a voluntary benefit and, depending on the business success of the insurer, the amount (up to six monthly premiums) is set anew every year.
  • Flat rate service - In addition to conventional reimbursement, individual insurers offer a contractually guaranteed flat rate service in current contracts if the customer does not provide services . Depending on the length of time you are exempt from providing benefits, it increases with some insurers up to six monthly premiums and, in contrast to conventional premium refunds, is paid regardless of the insurer's business success.
  • Claims discount - Similar to offer the no-claims bonus of car insurance isolated insurers now also in full health and additional area an annual increase in discount, no services provided to them. This can lead to a discount of up to 50 percent of the regular fee. It should be noted that this discount, based on e.g. B. in a year, as in motor insurance, only slowly (10 percentage points each). This is also a contractually guaranteed benefit from the insurer (see also no- claims discount ).

With regard to the rules for premium refunds, the insurance companies and their tariffs differ significantly. While some companies base the reimbursement of premiums on the entire monthly premium, others only use the tariff component for outpatient and dental treatment as a basis, so that the insured person does not receive a premium refund on the tariff component for inpatient treatment.

The premium refund can be carried out to avoid profits. Some PKV are mutual insurance associations (VVaG). Here, contributions can be reduced through the statutory profit sharing - that is the only way in which a VVaG can distribute surpluses.

Services

Treatment costs

The insured person receives an invoice for the treatment costs directly from the treating hospital, doctor or from a clearing office commissioned by the doctor . He then submits the invoice, as well as prescriptions and bills for medication, to his insurance company and, after an examination, receives a reimbursement in the amount agreed in the tariff.

Due to the requirement of medical confidentiality, billing via a clearing house is only permitted with the consent of the patient.

According to a ruling by the Federal Court of Justice , doctors and dentists are allowed to liquidate the "standard maximum rate", i.e. the average rate of increase (factor 2.3) of the fee schedule for doctors (GOÄ) or fee schedule for dentists (GOZ) for services that are difficult and / or time consuming on average . With the amendment of the GOZ on January 1, 2012, this was also clarified in this ordinance. Any upward deviation in the multiplier must be justified. If the 3.5-fold rate is exceeded, a written agreement with the patient is required before treatment begins. However, the reimbursement amount of the private health insurance can be limited to a certain multiplier (usually 3.5 times) by the regulations of the insurance tariff.

Billing

The basis of medical treatment is the treatment contract between patient and doctor. That is why privately insured persons receive an invoice after the treatment , which they can pass on to their health insurer for reimbursement after checking (similar to other insurance cases). In Germany it is usually unusual to pay a medical doctor immediately after treatment , for example in cash. This is in contrast to the practice of German veterinarians and human medicine practitioners in some other countries. For example, in the Netherlands the patient can often pay directly by bank card if he so wishes .

Privately insured persons check their doctor's or laboratory bills themselves, submit reimbursement applications to the PKV, check whether the reimbursement or partial reimbursement has been made and transfer the invoice amount . The Association of Private Health Insurance provides patients with a check program with which they can check medical bills. In the case of a patient being cared for , these tasks are part of the duties of the caregiver . If a patient or his caregiver with a partial refund or no refund does not agree, he may, after consultation with the private health insurance and possibly contradictory insert. A patient can also be obliged to pay if the health insurance company (or another reimburser) is not willing to reimburse - especially if the analogue services are excluded from reimbursement due to the tariff .

For hospital stays , the clinic expects usually the expenses with PKV from when the patient to the hospital a signed health insurance card ( clinic-card presents), with which he claims against the PKV at the hospital of treatment assigns . In this case, the patient will receive a copy of the invoice for information.

Which costs are reimbursable in individual cases is based on the agreed tariff for outpatient and inpatient treatment.

Privately insured person's right to information

If the costs of a treatment are expected to exceed EUR 2,000, according to § 192 VVG , privately insured persons are entitled to receive binding information from their insurance company prior to the start of the services provided by the insurance company. In the case of beneficiaries, the right to information applies from expected costs of EUR 1,000. In urgent cases, the insurance company must provide the information within two weeks, otherwise within four weeks. If the deadline is missed, the insured person can assume that the treatment was medically necessary and will therefore be reimbursed. If a reimburser refuses to accept the costs, the insured person must pay the costs himself if the invoice is correct.

The insurer is also obliged, at the request of the policyholder, to provide information and inspect reports or statements that he obtained when checking his obligation to provide benefits on the necessity of medical treatment ( Section 202 VVG).

In relation to doctors, insured persons or persons authorized to inspect them have the right to inspect treatment documents ( findings , surgery report , doctor's letter , x-ray, etc.). Exceptions only exist if there are significant therapeutic reasons, such as a mental illness, or if the rights of third parties could be violated.

Expenditure structure in the private health insurance

The health expenditure of private health insurance amounted to a total of 31.590 billion euros in 2017 (8.6% of all health expenditure in Germany amounting to 368.597 billion euros). They were distributed as follows:


Facilities 		Private health insurance expenditure
in billions of euros 		PKV share

in percent

Hospitals 8,937 28.29%
Doctor's offices 6.524 20.65%
Administration including marketing 3,686 11.67%
Pharmacies 3.525 11.16%
Dental offices 4,346 13.76%
Other med. Practices 1.414 4.47%
Other expenses 3.158 10.00%
Total expenditure 31,590 100.00%

Source: Federal Statistical Office

criticism

Private health insurance is repeatedly cited as an example of two-class medicine . Many citizens would like to be able to switch between statutory and private health insurance regardless of income. In addition, experts assume that the contributions could fall significantly if all citizens would pay into the statutory health insurance. The German Medical Association continues to reject this.

See also

Web links

Individual evidence

  1. ^ Association of Private Health Insurance eV: Figures Report of Private Health Insurance 2016 p. 23, 32
  2. ↑ dlullies: Association of Private Health Insurance eV: Facts & Figures. In: www.pkv.de. Retrieved January 4, 2017 .
  3. ↑ Numerical reports from the PKV Association. Retrieved March 17, 2015 .
  4. ↑ Figures report from private health insurance 2017. Accessed on November 19, 2019 .
  5. ↑ Figures report from private health insurance 2017. Accessed on November 19, 2019 .
  6. ↑ Figures report of private health insurance 2017 ( Memento from December 1, 2017 in the Internet Archive )
  7. ↑ Privately insured civil servants will pay taxpayers 60 billion additional costs by 2030 on heise.de , January 10, 2017
  8. ↑ Federal Government: New assessment limits for 2019. September 27, 2017, accessed on October 29, 2017 .
  9. ↑ Why there isn't the best policy for everyone
  10. ↑ The new unisex tariffs. Retrieved February 25, 2020 .
  11. ↑ Easier admission to private health insurance for civil servants and their relatives - opening campaigns for private health insurance. (PDF) In: https://www.pkv.de/ . Private Health Insurance Association, March 2019, accessed August 26, 2019 .
  12. ^ Federal Social Court, Az: B 4 AS 108/10 R
  13. ^ Federal Social Court judgment of October 16, 2012, Az .: B 14 AS 11/12 R
  14. ↑ Thomas Schmitt: The stony way back to health insurance. In: www.handelsblatt.com. February 22, 2012, accessed July 12, 2019 .
  15. ^ Advice on health insurance, 15th updated edition: as of November. (PDF) Federal Ministry of Health, 2017, accessed on July 12, 2019 . Chapter 1, Section “1.1.3 Voluntarily Insured”, pp. 25–26.
  16. ↑ Insured in the statutory health insurance. In: Online health insurance advice, www.bundesgesundheitsministerium.de. Federal Ministry of Health, January 24, 2018, accessed on July 12, 2019 .
  17. ↑ Exemption from compulsory insurance. In: www.studentische-versicherungen.de. Retrieved July 12, 2019 .
  18. ↑ The increase in the contribution assessment ceiling in 2019 and its consequences. In: www.derprivatpatient.de. Retrieved November 2, 2019 .
  19. ↑ Do I get an employer's subsidy for private health insurance? In: Website of the PKV Association. Retrieved November 2, 2019 .
  20. ↑ Fact sheet - Topic: Calculated variables and limit values ​​in insurance and contribution law for 2012 from December 15, 2011 (PDF; 120 kB) GKV-Spitzenverband. Archived from the original on October 2, 2012. Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Retrieved October 12, 2012. @1@ 2Template: Webachiv / IABot / www.gkv-spitzenverband.de
  21. ^ General insurance conditions for the standard tariff MB / ST 2009, tariff conditions, tariff ST . Retrieved February 15, 2014.
  22. ^ KV Berlin information for practice. Topic PKV - difference between standard tariff and basic tariff , as of February 2010 . Retrieved February 10, 2014.
  23. ↑ General insurance conditions for the emergency tariff AVB / NLT 2013, tariff NLT
  24. ↑ Press release of the Federal Ministry of Health: More protection for premium debts , last accessed on August 26, 2013.
  25. ↑ Debt trap eliminated. Federal Government, September 18, 2013, accessed December 10, 2015 .
  26. ↑ The new emergency tariff in private health insurance , last accessed on January 19, 2020.
  27. ↑ Unisex tariffs are expensive for private health insurance customers , Ärztezeitung
  28. ↑ Jürgen Wasem : Independent commission of experts to investigate the problem of increasing contributions by privately insured people in old age. Assessment. Bundestag printed paper 13/4945 (PDF; 2.2 MB)
  29. ↑ Study on the increase in premiums in private health insurance (2011)
  30. ↑ Catherine Hoffmann: “ The private ones strike too ” FAZ of December 17, 2007
  31. ↑ Competition in the field of private health insurance (PDF; 1.4 MB) IGES Institute. January 25, 2010. Retrieved December 10, 2015.
  32. ^ DAV on the development of contributions in private health insurance . June 25, 2011. Retrieved December 10, 2015.
  33. ↑ https://www.pkv.de/service/zahlen-und-ffekten/
  34. ↑ Aging provisions in private health insurance. (PDF) Association of Private Health Insurance, accessed on December 10, 2015 .
  35. ↑ Holger Fahl: Title Corporate Governance in Insurance Association a. G .: The effects of the company law reforms on the system of corporate management and control in the VVaG. Verlag Versicherungswirtsch., 2005, ISBN 3-89952-183-8 , page 31.
  36. ↑ Janusz Council : GOZ primer. Comment on the calculation of selected services. (PDF) Bavarian State Dental Association (BLZK), March 1, 2002, archived from the original on December 30, 2008 ; Retrieved March 11, 2008 . P. 52.
  37. ^ Peter Klotz, Hubert Heindl, Jürgen Marbaise: GOZ primer of the Bavarian State Dental Association (BLZK) on the fee schedule for dentists (GOZ). (PDF) Bavarian State Dental Association (BLZK), January 2005, accessed on December 1, 2019 . Section “Factoring”, p. 35.
  38. ↑ BGH, Az: III ZR 54/07 of November 8, 2007 . Juris.bundesgerichtshof.de. November 8, 2007. Retrieved June 25, 2010.
  39. ↑ Billing of your medical treatment. In: derprivatpatient.de. 2019, accessed December 1, 2019 .
  40. ↑ Check the doctor's bill. In: derprivatpatient.de. 2019, accessed December 1, 2019 .
  41. ↑ Janusz Council : GOZ primer. Comment on the calculation of selected services. (PDF) Bavarian State Dental Association (BLZK), March 1, 2002, archived from the original on December 30, 2008 ; Retrieved on March 11, 2008 : “If an insurance company, aid agency or other reimburser does not reimburse the invoice or parts of the invoice, this does not entitle the debtor to reduce the payment amount accordingly. Claims made by a reimburser that certain calculations in the liquidation are not legal are often made out of a special interest situation and experience has shown that they are often wrong. ” P. 46.
  42. ^ Peter Klotz, Hubert Heindl, Jürgen Marbaise: GOZ primer of the Bavarian State Dental Association (BLZK) on the fee schedule for dentists (GOZ). (PDF) Bayerische Landeszahnärztekammer (BLZK), January 2005, accessed on December 1, 2019 : "In the case of individual analog services, it is advisable to inform the patient in advance about possible reimbursement difficulties or tariff-related reimbursement exclusions, which unfortunately are caused by reimbursers and thus the insured withheld the reimbursement of dental progress benefits. The possibility of analog calculation of such services remains unaffected. ” Section“ Analog services are GOZ services ”, p. 29.
  43. ^ Bavarian State Dental Association: GOZ Primer. Comment on the calculation of selected services p. 35.
  44. ↑ © Federal Statistical Office (Destatis): Federal Statistical Office Germany - GENESIS-Online, Table 23611-0004. November 19, 2019, accessed November 19, 2019 .
  45. ^ Rolf-Herbert Peters, Lorenz Wolf-Doettinchem: Two-Class Medicine: Interior View of an Unjust Health System . In: Stern . No. 51 , 2005 (title).
  46. ↑ "Patients are the ones who suffer" . In: Franconian Day . September 6, 2006, p. 4 .
  47. ↑ Study: With only one health insurance, premiums could drop noticeably. In: Handelsblatt. February 17, 2020, accessed July 8, 2020 .
  48. ↑ Rainer Stadler: More justice for health insurance patients. In: Süddeutsche Zeitung. February 17, 2020, accessed July 8, 2020 .