Private health insurance – when the insurer refuses benefits
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If private health insurance doesn't pay
Private health insurance protects against substantial treatment costs in case of illness. Surgeries, hospital stays, specialized therapies, or modern treatment methods can quickly lead to significant financial burdens. Policyholders therefore rely on their private health insurance to cover the agreed-upon benefits when needed.
However, if it comes to Rejection When costs are denied or benefits are reduced, policyholders often face an existential crisis. Insurers frequently argue that there is no medical necessity, that the treatment is not covered, or that certain policy conditions have not been met.
Rogert & Ulbrich, represented as lawyers in Insurance law We advise insured persons nationwide on insurance law and examine whether the decision of the private health insurance company is legally valid and what claims can be enforced.
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3When is there an entitlement to benefits in private health insurance?
In order to claim benefits from private health insurance, an illness as defined in the insurance terms and conditions must first be present. An illness is defined as an objectively identifiable physical or mental condition that deviates from the normal state of health.
Furthermore, the treatment must be medical. Medical treatment is defined as measures aimed at curing, alleviating, or improving an illness, or preventing its worsening. Treatments that replace or stabilize bodily functions may also be included under certain conditions.
The central requirement is medical necessity. This is determined according to objective criteria. It is generally sufficient if a treatment is medically justifiable. It is not necessary that it be the only possible form of therapy.
It is precisely at this point that disputes often arise between the insured and the insurer.
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Medical necessity and modern treatment methods
Insurers often reject claims under private health insurance on the grounds that a measure is not medically necessary or that there are more cost-effective alternatives.
According to case law, however, the decisive factor is whether the chosen treatment was medically justifiable. Particularly in cases of serious or life-threatening illnesses, new or alternative therapies may also be reimbursable if there is at least a not entirely remote prospect of improvement.
The interpretation of the insurance terms and conditions in each individual case is crucial. A blanket rejection by the insurer is legally reviewable.
If your insurance company is causing problems – talk to lawyer Dario Kovac
Is your insurance company refusing to pay or delaying the settlement? Lawyer Dario Kovac He has been assisting clients with disputes with insurance companies, particularly legal expenses insurers, since 2019. His previous work at ARAG He is familiar with typical rejection strategies from practice.
- Review of your benefit claim
- Consistent enforcement
- No communication with the insurance company
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Being kicked out of private health insurance
The situation is particularly serious if the insurer not only refuses individual benefits, but terminates, contests, or withdraws from the contract as a whole.
This often occurs in connection with the review of submitted invoices. The insurer retrospectively checks the information in the original application and cites an alleged breach of the pre-contractual duty of disclosure.
Such a step has significant consequences. In the worst-case scenario, insured individuals could find themselves without insurance coverage, even though health insurance is mandatory. However, whether a challenge or cancellation is legally valid depends on strict legal requirements.
A thorough examination of each individual case is essential here.
Contribution adjustments and benefit limitations
In addition to claims being rejected, private health insurance companies regularly adjust their premiums. Here, too, the question arises whether the adjustment is formally and materially valid.
Furthermore, many tariffs contain exclusions or limitations, for example regarding certain types of treatment, dental prosthetics, or psychotherapy. Whether such a clause is legally valid can be clarified through a review of the terms and conditions.
In insurance law, unclear or surprising clauses may be invalid under certain circumstances.
Dispute over the eligibility for reimbursement of individual cost items
Legal aid
It is not uncommon for disputes with private health insurance companies to concern not the entire treatment, but individual items on the bill. For example, the insurer may reduce doctors' fees, citing allegedly excessive billing rates, reject additional charges for elective services in hospitals, or refuse to reimburse certain medications.
Discrepancies regularly arise, particularly when billing according to the German fee schedules for physicians (GOÄ) or dentists (GOZ). However, the insurer is not entitled to categorically reject individual items without examining the contractual basis and the medical indication in the specific case. The decisive factor is whether the billed services are medically necessary and covered by the policy.
A detailed legal and fee-related analysis by a specialized lawyer can be crucial in enforcing full reimbursement.
Limitations on benefits for psychotherapy, dental prostheses and assistive devices
Many private health insurance plans contain special provisions regarding psychotherapy, dental prosthetics, or assistive devices such as dentures, hearing aids, or orthopedic devices. These often include maximum limits, tiered reimbursement rates, or prior authorization requirements.
Whether such a limitation of benefits is effective depends on the specific wording of the insurance terms and conditions. Unclear or surprising clauses may be invalid. Furthermore, it must be verified whether the insurer has correctly applied the tariff regulations.
Especially in the case of costly treatments, an incorrect limitation of benefits can have significant financial consequences, which is why a review by a lawyer is advisable.
Changing tariffs within private health insurance
Under certain conditions, policyholders have the right to switch to a different tariff within their private health insurance. This right to change tariffs can be particularly relevant if premiums increase significantly or benefits are adjusted.
The insurer is obligated to inform policyholders about alternative tariffs with comparable coverage. In practice, however, this information is not always transparent or complete. Legal counsel from a lawyer specializing in insurance law can help to correctly assess existing claims for tariff changes and to make economically sound decisions.
Practical examples from private health insurance
In one case, a private health insurance company refused to reimburse a specialized operation, arguing that it was not medically necessary. However, by obtaining a supplementary expert opinion, it was demonstrated that the chosen therapy was medically justifiable and appropriate in the specific case. The insurer then covered the costs.
In another case, after several medical bills were submitted, the insurer declared its withdrawal from the contract due to allegedly incomplete information in the application. A legal review revealed that there had been no intentional or grossly negligent breach of the duty of disclosure. The insurance coverage remained in effect.
These examples illustrate that decisions made by private health insurers should not be accepted without scrutiny.
10 Questions & Answers about Private Health Insurance
Have your benefit denial legally reviewed now.
If your private health insurance refuses to provide benefits, does not reimburse bills, or wants to terminate your contract, you should not accept the decision without question.
Have your case reviewed by an experienced insurance lawyer to clarify what claims you are entitled to against your private health insurance company. Schedule an initial consultation and gain clarity about your legal position.
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