The relationship between private health insurance companies and the insured person is not always without conflict. A common cause of disputes is that health insurance companies refuse to reimburse costs. What can you do as an insured person to avoid being stuck with the costs?
Insured persons must pay in advance
A major advantage of private health insurance (PKV) is that the tariffs can be individually adapted to the personal needs and wishes of the insured. This enables tailor-made coverage that is not available in statutory health insurance. Insured persons can therefore choose services that go beyond the standard offer and correspond to their individual preferences. A major disadvantage of private health insurance, however, is that insured people often have to pay in advance. This means that you initially bear the costs of medical treatment yourself and are only reimbursed subsequently by your health insurance. This can be a financial burden, especially with expensive treatments. In addition, when using medical services, a contractual relationship actually arises between the insured person and the service provider (e.g. doctor, hospital). The insurance company is not directly involved. The insured person therefore has separate claims against his health insurance company for reimbursement of the costs incurred. Problems can arise if the private health insurance company refuses to cover certain costs. This can be the case, for example, if the health insurance company questions the medical necessity of treatment or identifies errors in billing. For many insured persons, who often do not deal in detail with the specific regulations and conditions of their health insurance, it can be difficult to evaluate the justification of such decisions and, if necessary, to lodge an objection.
Contact your doctor and ask for written reasons
According to the consumer advice center, health insurance companies are generally only obliged to cover the costs of medically necessary treatments, which are also billed within the agreed tariff conditions and the applicable fee schedule. Problems with reimbursement often arise when the health insurance company questions the medical necessity of treatment or notices discrepancies in billing. In cases where the insurer objects to a bill, correcting the billing can often help resolve the issue. However, if the health insurance company continues to refuse to cover the costs, it may be necessary for the insured person to take legal action. The consumer advice center advises those affected to contact the treating doctor’s billing office immediately if the health insurance company rejects the offer. It is advisable to forward the rejection letter from the health insurance company directly to the medical facility in order to request a professional opinion. This statement should explain the reasons why the particular treatment was carried out and billed for. The medical opinion should then be forwarded to the health insurance company without delay in order to clarify the situation. If this step does not lead to a positive decision from the health insurance company, the consumer advice center recommends asking the insurance company to contact the treating doctor directly.
Ombudsman for out-of-court arbitration
If an agreement cannot be reached even after obtaining a medical opinion and direct communication between the insurance company and the medical professionals, the consumer advice center recommends contacting the ombudsman for private health and nursing care insurance as the next step. The ombudsman serves as an out-of-court arbitration body and is tasked with resolving conflicts between insured persons and their health insurance companies without leading to legal proceedings. Heinz Lanfermann, a lawyer with experience as a state secretary and member of the German Bundestag, takes on this role and offers a neutral platform for resolving disputes. Should a legal dispute nevertheless arise, for example because a doctor or a billing office files a lawsuit, the consumer advice center advises the insured to seek legal support from a lawyer who specializes in insurance law. A lawyer who is familiar with the specifics of private health insurance can help you effectively enforce your own claims and explore your legal options. Ultimately, if the ombudsman’s attempt at mediation does not bring a solution, legal action remains the ultimate means of resolving the dispute. In such cases, it is important to obtain expert legal advice in order to best represent your own rights and claims.
Editorial team finanzen.net