Deductible

from Wikipedia, the free encyclopedia

Under excess ( deductible , co-payment , cost sharing or co-payment , even franchises ) are understood in insurance the part which the policyholder in the insurance case has to bear itself (either annually or per incident). It is stipulated by law or contractually agreed as an absolute or percentage share. The insurance will only pay sums in excess of this.

General

In composite insurance as well as in personal insurance, the deductible is the insurer's incomplete assumption of an insurable risk. From the perspective of the insured person, the excess is an uninsured personal risk because he has to bear the risk that is subject to the excess himself. The policyholder is left with a certain risk share (deductible rate). The purpose of the deductible is, on the one hand, to lower insurance premiums because the insurance company does not bear the entire risk of damage. On the other hand, it forces the insured to be careful when avoiding insured risks and thus tries to reduce or eliminate the effects of moral hazard . The deductible makes sense where the insured person can influence the risk of damage himself. High deductibles increase the policyholder's interest in loss prevention measures. The deductible is therefore a control instrument that can reduce the incentive of insurance-induced demand. The deductible is to be distinguished from the self-insurance , because the deductible counts as non- insurance . Existing deductibles result in selection effects because they can separate bad from good risks.

Deductible

A common form of deductible is the deductible. It sets a fixed amount up to which the policyholder bears his own damage, while higher damage costs are reimbursed with deduction of the deductible amount.

The integral deductible is a special form of deductible franchise . With her, the insurance pays the entire damage if the damage exceeds a certain amount agreed in advance. The aim of the integral deductible is to avoid having to deal with minor claims. This type of franchise is not very well known, but it is common for the insurance of IT systems, for machine and transport insurance and also for accident insurance for professional athletes (soccer players, etc.). The risk with integral franchise is that policyholders may violate the duty to minimize damage by increasing the damage above the deductible.

Time deductible

In the case of the pure time franchise, the policyholder bears the damage that is attributable to the franchise period in full, the damage that occurs after this time is borne by the insurance company until the end. For example, a time deductible of 10 days is agreed for business interruption insurance. Interruptions of up to 10 days are fully borne by the policyholder. If an interruption lasts longer, the damage that exceeds 10 days will be borne by the insurance company.

With the proportional time franchise, the policyholder's share in the total loss is as large as the franchise period in the total loss period. For example, in a daily sickness allowance insurance (with a non-constant amount of the daily payment) a time deductible of ten days is agreed. The insured person is sick for thirty days, then has a deductible of 10/30 of the total damage.

Health insurance

Basic considerations on the subject of co-payments in the event of illness

Patients' own contributions are intended to curb costs and reduce the expenses of the payers. However, this financing function and the postulated control function are already in inverse proportion to one another in theory: the higher the additional payments, the more people are prevented from using health services and accordingly bring little or no money into the system; conversely, small co-payments will keep fewer patients away, so that the control function will be less. It is controversial whether the control effect can be achieved at all.

A comprehensive Austrian study in 2002 examined the deductibles in the healthcare system in Germany, Finland, Great Britain, Italy, the Netherlands, Sweden, Austria and the USA. Thereafter, a deductible is used to finance, control and redistribute. According to the study, in order to ensure that health services can be financed, attempts are being made in most countries to strengthen market mechanisms and competitive elements in the health sector. One of these measures is the introduction of deductibles.

Germany

Statutory health insurance deductibles

In the statutory health insurance there are different forms of deductibles: Since the statutory health insurance principle is based on the principle of benefits in kind , i.e. the insured person does not have to submit a submission, the deductibles are designed in such a way that the insured person pays a partial amount to the service provider ( pharmacist , medical supply store , physiotherapist , Hospital, etc.) have to pay themselves. This includes, for example, co-payments for bandages, medication, aids , remedies , home nursing , hospital treatment, rehabilitation, travel expenses or household help . Since the practice fee no longer applies, there is no additional payment to the doctor in Germany.

Voluntary deductibles are those that on the one hand do not have to be offered by every health insurance company, but on the other hand are also voluntary for the insured. The incentive to accept a deductible is the payment of a bonus in return, for example in the form of a fixed sum. On the one hand, these tariff variants, called optional tariffs , aim to encourage insured persons to use benefits more efficiently. They also enable more attractive tariffs for people who use services less often and introduce individual tariff elements into statutory health insurance in Germany. The former happens when certain services are subject to monetary disadvantages. For example, a visit to the doctor and a prescription issued can include a deductible, which in turn reduces the bonus. The bonus is always less than the maximum deductible. So if you go to the doctor frequently in this example and receive prescriptions, you run the risk of paying more deductible than receiving a bonus. This tariff variant has been possible since the 2007 health reform , which came into effect on April 1, 2007.

Co-payments

In the statutory health insurance, insured persons who have reached the age of 18 have had to make the following additional payments since 2004 (see also § 61 SGB ​​V ):

  • Medicines and aids: 10% of the selling price , a minimum of € 5.00, a maximum of € 10.00 for medication, never more than the selling price itself. B. Aids that are used up such as incontinence aids or filters for ventilators. The minimum rate of € 5.00 does not apply to them, but the upper limit of € 10.00 per month does. Since July 1, 2006, particularly inexpensive drugs, i. H. especially generics , exempt from co-payment. Currently there are around 3,700 drugs.
  • Hospital: € 10.00 per calendar day, for a maximum of 28 days per calendar year.
  • Rehabilitation: € 10.00 per calendar day. It may be possible to reduce the co-payment costs by offsetting a directly preceding hospital stay (e.g. detoxification treatment before weaning treatment), then the co-payment period amounts to a total of 28 days (with the previous hospital days being taken into account).
  • Remedies: € 10.00 prescription fee, plus 10% of the selling price.
  • Domestic help: 10% of the service per day, minimum € 5.00, maximum € 10.00, never more than the amount of the benefit.
  • Travel costs: 10% of the reimbursement per trip, minimum € 5.00, maximum € 10.00, never more than the amount of the benefit. Here children also have to make an additional payment.
Exemption from co-payments

An individual maximum amount applies to all co-payments in a calendar year ("load limit", Section 62 of the Social Code Book V). It is calculated from 1 or 2% of the gross household income available for subsistence minus allowances for family members. The limit of 1% applies if the family doctor certifies that one or more family members have a serious chronic illness that has been treated by a doctor for at least 12 months. The allowances for family members for the spouse are 15% of the reference value according to Section 18 SGB ​​IV , in 2019 that is € 5,607, for each child € 7,620. By paying this maximum amount in advance (minus any additional payments already made in the relevant calendar year), you are exempt from paying additional payments for the calendar year.

Co-payments for Alg II (Hartz IV) or social assistance are limited to € 103.68 in 2020 (2% limit, half for the chronically ill). This amount is calculated from the standard requirement (€ 432 x 12 months: 100 x 2 or 1). (As of January 1, 2020)

Own shares

A co-payment should not be confused with an additional payment. It is the amount that the insured person has to pay for the cost of an aid, which corresponds to the amount that he would have had to spend if he had bought the product as a healthy person without medically necessary care.

Example: If a pair of orthopedic shoes costs a certain amount, which the orthopedic shoe technician receives from the cost bearer (the health insurance company), the beneficiary must bear the additional payment (see above) as well as the co-payment of (in 2019 for street shoes for adults) 76 , 00 €. The legislator assumes that he could have bought a pair of shoes with this amount if he hadn't needed orthopedic shoes.

The same regulations (but with different co-payment amounts) apply e.g. B. in breast prosthesis bras and bathing suits.

Optional tariffs

Optional tariffs are a partly voluntary, partly legally prescribed offer from health insurance companies that can be used by the insured. There are two variants, although not all health insurances offer both:

  • Premium reimbursement if no benefits are paid: If the insured person and adult co-insured person do not make use of any benefits, they receive a certain bonus, a maximum of one monthly contribution (including employer's contribution). The tariff is concluded for a year, with some health insurances the bonus received increases in the 2nd and 3rd year. In principle, taking out this optional tariff has no risk for the insured person, but it increases the pressure not to go to the doctor despite illness or to pay for the doctor's visit himself. The latter cannot be settled retrospectively with the health insurance company.
  • Deductible (deductible) in the strict sense: The insured person (excluding his co-insured persons) undertakes to pay a certain annual amount of any costs himself over the next three years. For this he receives a lower bonus from the health insurance company, but a maximum of 600 euros per year.

The tariffs can (or must) be combined with some health insurances, in which case 900 euros per year can be received.

The behavior of insured persons when making use of benefits is to be influenced by the incentive of a bonus or a premium saving. To avoid negative developments such as the complete waiver of visits to the doctor, control mechanisms are integrated into the tariffs: Depending on the tariff structure, for example, visits to the doctor for preventive purposes or visits to the doctor without a prescription are irrelevant for the deductible, so they do not cost the patient any money. Furthermore, some tariff models try to avoid excessive risks for low income groups by choosing the maximum deductible higher with increasing income (but sometimes also having to), whereby the bonus received increases (to a lesser extent).

Optional tariffs indirectly lead to an individual influence on the amount of the contribution to the health insurance, as certain actions of the insured are punished by monetary effects, others are given incentives. The control effect is controversial. Apart from that, it is an instrument to make the solidarity principle more interesting for people with higher incomes and few benefits, by reducing the contribution amount for them when using these tariffs.

Economic surcharge

There are fixed prices for various products in the supply of medical aids: The service provider only receives this price from the cost unit (the health insurance company), regardless of the manufacturer's recommended retail price.

“Economic surcharges” are only to be paid by the insured person in the event of a provision exceeding the necessary level. "If insured persons choose aids or additional services that go beyond what is necessary, they have to bear the additional costs and the resulting higher follow-up costs themselves." ( Section 33 (1) SGB V). So if a service provider (e.g. medical supply store) requires an "economic surcharge" for standard supply without a special request, you should inquire with the service provider again. You can also get advice from consumer advice centers and health insurance companies.

Social impact

A socially unacceptable burden on the insured is to be avoided by the so-called overload limits (2% of gross income, 1% in the case of chronic illnesses). Note: The statutory health insurance defines the term "chronic illness" differently than science. Seriously chronically ill within the meaning of the KV is anyone who is under constant medical treatment or is severely disabled or in need of care, at least to the extent that they are dependent on daily help (care level 2 or 3 or 60% disability) or a doctor certifies that they are that his illness would worsen life-threateningly without treatment and thus his life expectancy would be reduced or his quality of life would be permanently impaired.

Co-payments have the greatest impact on socially disadvantaged groups and the chronically ill; this particularly affects regular, adequate medication intake. This is problematic if an initial visit to the doctor would be useful. The Austrian Federal Institute for Health Care sees deductibles as follows: "Deductibles primarily affect weaker groups such as the chronically ill and people with low incomes and thus come into conflict with the social goals of the solidarity community."

Voluntary deductibles (optional tariffs) of some health insurances try to cushion this disadvantage by offering lower deductibles with lower bonuses for low income groups. In this way, the maximum risk can be adapted to the income group.

Deductible in private health insurance

In private health insurance , in which the reimbursement principle applies, the insured person does not receive any reimbursement benefits from the insurer in the amount of the agreed deductible. As a result, the deductibles also influence the contribution to be paid by the insured person (the insurance premium).

With the deductible, the insurance ensures that the insured do not settle smaller bills with it, which among other things also saves administrative costs for the insurer. In Germany, the deductible is limited to a maximum of 5,000 euros per insurance year ( Section 193 (3) VVG).

Various insurance companies offer premium refunds in their contracts if the insurance service is not used. a. contributes to the stability of contributions, but also to an increase in personal contributions by the insured.

If there is no damage or depending on the amount of damage, an amount is paid to the insured at the end of an insurance period. If the repayment is only made if there are no damages, the result corresponds to a deductible. As long as the health expenditure falls below the amount of the premium refund, it is worthwhile for the insured person to bear the health expenditure himself. In the case of higher expenses, however, the insured person will forego the refund of contributions; it then represents the deductible to be paid.

Austria

In the opinion of the Austrian Ministry of Health, the ambulance fee levied from 2001 to 2003 should divert “misdirected patient flows” from the overburdened, more expensive ambulances to the resident area in the Austrian health system .

Switzerland

In the compulsory basic insurance, part of the treatment costs are borne by the insured. The cost sharing consists of:

  • the ordinary deductible (fixed amount). It is CHF 300 per year (“Despite many incentives to save, costs rise”, FAZ July 3, 2006), although children and young people up to the age of 18 do not pay a proper deductible. Higher deductibles can be chosen voluntarily, whereby the insurance premium (contribution of the insured person) is reduced accordingly.
  • the deductible of 10% of the remaining invoice amount, but up to a maximum of 700 francs per year (children and young people up to 18 years of age: 350 francs).
  • Since 2006 the deductible has been 10% for generics and 20% for original drugs (for which generics are on the market).
  • People who do not live in the same household with one or more people with whom they have a family law relationship make a contribution towards the costs of a hospital stay of CHF 10 per day (with no time limit), except in the case of maternity.

The benefits of normal maternity (complications of pregnancy are considered illnesses and are covered by the cost sharing) and specially designated preventive measures are excluded from cost sharing.

In Switzerland, the share of expenses not paid for by insurance is particularly high: according to OECD figures, cash expenses (“out-of-pocket payments”) per inhabitant are $ 2,166 (2008). This corresponds to 30.8% of the total expenditure. In no other OECD country, not even in the USA ($ 912, 13%) is the self-payer burden as high. The OECD average is $ 599.

See also: health insurance in Switzerland

Composite insurance

Deductibles are also common in composite insurance, which includes all accident and damage insurances except health insurance. Here tangible assets are insured or risks in liability risks blocked. Deductibles occur in motor insurance , general liability insurance , accident insurance , legal protection insurance , property insurance or transport insurance . Industrial and commercial insurance such as credit , surety , fidelity , business interruption and export credit insurance know the deductible.

Web links

Wiktionary: Deductible  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. Alfred Endres, Economic foundations of liability law , 1991, p. 185 ( limited preview in the Google book search).
  2. Dieter Farny et al. a., Hand Handbuch der Versicherung HDV , 1988, p. 779 ( limited preview in the Google book search).
  3. Günter Festl u. a., Volkswirtschaftslehre… , 2002, p. 763 ( limited preview in the Google book search).
  4. Austrian Federal Institute for Health Care, Deductibles - International Comparison and Implications for Austria , November 2002 ( PDF, 2.5 MB ( Memento of the original from September 24, 2015 in the Internet Archive ) 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 note. , goeg.at), p. 22. @1@ 2Template: Webachiv / IABot / www.goeg.at
  5. Austrian Federal Institute for Health Care, Deductibles - International Comparison and Implications for Austria , November 2002 ( PDF, 2.5 MB ( Memento of the original from September 24, 2015 in the Internet Archive ) 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 note. , goeg.at). @1@ 2Template: Webachiv / IABot / www.goeg.at
  6. Austrian Federal Institute for Health Care, Deductibles - International Comparison and Implications for Austria , November 2002 ( PDF, 2.5 MB ( Memento of the original from September 24, 2015 in the Internet Archive ) 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 note. , goeg.at), p. 9. @1@ 2Template: Webachiv / IABot / www.goeg.at
  7. ^ Federal Ministry of Health: Remedies and Aids. Accessed November 3, 2008. Online [1] .
  8. see also administrative agreement on § 62 SGB V (PDF; 15 kB)
  9. Optional tariffs of the health insurance companies , article of the consumer advice centers , April 11, 2018, accessed on July 31, 2018