Private health insurance benefits: what private cover pays for

The benefits of private health insurance are not a fixed catalog as in statutory health insurance. Each plan sets its own reimbursement rates, limits and conditions for the four areas. Two plans of the same insurer can differ more in their scope of benefits than two plans of different providers.

Four areas shape the scope of benefits. Outpatient: doctor visits and specialists without a referral, diagnostics, medicines, therapeutic remedies and medical aids, and prevention. Inpatient: general hospital services, and in comfort plans optional hospital services such as chief physician treatment and a single room. Dental: dental treatment and prophylaxis, and dentures with graduated reimbursement of 50 to 100 percent. Health resort stays and rehabilitation: these benefits depend on the specific plan terms.

Legally, every reimbursement rests on two pillars. § 192 VVG obliges the insurer to reimburse the agreed expenses for medical treatment. § 1 (2) MB/KK requires the treatment to be medically necessary. In practice, most reimbursement questions are decided by this wording.

Outpatient benefits include treatment by family doctors and specialists, laboratory tests, imaging diagnostics and medicines, therapeutic remedies and medical aids prescribed by a doctor. Billing generally follows the reimbursement principle. The patient receives the bill and then submits it to the insurer. Reimbursement covers the scope agreed in the contract.

Medical services are usually billed under the fee schedule for doctors. The standard maximum rate is 2.3 times the base fee for personal medical services, 1.8 times for medical-technical services and 1.15 times for laboratory services. In cases of particular difficulty or extra time, the doctor can bill up to the relevant maximum rate with a clear justification. For personal services, this is usually 3.5 times. Even higher fees generally require a prior written fee agreement.

Whether bills above the standard maximum rates are reimbursed in full depends on the plan terms. So an out-of-pocket share does not arise with every specialist visit. It only arises when the bill exceeds the insured reimbursement range or other plan limits apply.

Preventive checkups, visual aids, alternative treatment methods, therapeutic remedies and medical aids are also reimbursed in line with the chosen plan. For medicines, the statutory fixed amounts and prescription charges of statutory health insurance do not apply automatically. What counts is which prescribed medicines the plan reimburses and to what level. Non-prescription products are often only reimbursable if a doctor prescribes them and the plan explicitly includes them.

General hospital services, that is accommodation, nursing care and treatment by the doctors on duty, are included in every comprehensive plan. The difference between plans lies in the optional hospital services. Treatment by the physician of choice, often called chief physician treatment, and accommodation in a single or two-bed room are standard in comfort plans and often not included in entry-level plans.

In addition, some plans promise a hospital daily allowance, a fixed amount per day in hospital. Many plans also reimburse treatment in private clinics. Rehabilitation and health resort stays, by contrast, are a separate field. Many plans limit these benefits or exclude them, because other bodies are often responsible for rehabilitation. If follow-up rehabilitation matters to you, check the clauses before you sign.

For dental benefits, plans separate dental treatment, dentures, implants and orthodontics. Good plans reimburse dental treatment such as fillings in full, and professional teeth cleaning once or twice a year depending on the plan. For dentures, reimbursement ranges from 50 to 100 percent, depending on the plan class.

A special feature of private health insurance is the dental benefit limits. In the first years of insurance, reimbursement for dentures is capped at fixed maximum amounts that rise each year. This mechanism protects the community of insured people from major treatments planned at short notice.

Whether private health insurance covers the costs of rehabilitation or a health resort stay depends on the plan and on whether another body pays first. Medical rehabilitation is meant to restore health and the ability to work. A health resort stay usually serves prevention or stabilization. Follow-up rehabilitation often comes directly after a hospital stay.

Before you start, clarify in writing whether the measure is insured in your plan, whether the pension or accident insurance is responsible first, whether the chosen facility is recognized, whether prior confirmation of cover is required and whether you are entitled to Krankentagegeld during the stay.

The key point is this: medical necessity alone is not enough. Plan terms, the paying body and the facility also decide.

In Europe, the benefits of private health insurance usually apply without a time limit, worldwide for one to twelve months per trip, depending on the plan. Good plans include medically sensible transport back to Germany. The clause on customary local costs is important. If you travel to countries with higher treatment prices, you need a plan that does not only reimburse German fee rates.

On top of this, components such as patient transport and rescue costs round off the cover. These items look small, but in an emergency they quickly reach four-figure amounts and therefore belong in every comprehensive plan.

In our advice work we see that most disputes between insured people and insurers do not arise over the premium. They arise over the GOÄ factor and the annual maximums. These two settings are rarely the focus when people sign.

In a plan comparison, we recommend that you give the GOÄ factor and the annual maximums more weight than a premium difference of twenty euros. In practice, the comfort of the plan makes the difference, not the starting premium.

Reimbursement depends on the plan, not on the insurer. The same provider often runs plans with 70 and with 100 percent reimbursement for dentures side by side. If you expect dentures in the coming years, choose a high level.

It is the basic requirement for any reimbursement under § 1 (2) MB/KK. A treatment is medically necessary if, based on objective medical findings, it was reasonable to regard it as necessary. Comfort services without a medical reason do not qualify, even in the best plan.

No. The benefits agreed in the plan are guaranteed by contract, and under § 206 VVG the insurer cannot give ordinary notice in comprehensive health insurance. Rising costs affect the premium, not the scope of benefits.

In principle, yes, through a plan change under § 204 VVG with the same insurer. For additional benefits, the insurer may ask new health questions or agree a benefit exclusion for the additional benefit. An extension therefore works best in healthy years.

Above 3.5 times the base fee, the doctor needs an individual fee agreement that the patient signs before treatment. Most plans do not reimburse these amounts. Some top-tier plans also reimburse above the maximum rates. If you regularly see highly specialized doctors, check this point in the plan.

Civil servants receive Beihilfe from their public employer, usually 50 to 80 percent of medical costs. With a Restkostentarif (i)RestkostentarifA private plan that covers the share of medical costs that Beihilfe does not pay. Together with Beihilfe it gives civil servants full cover.More about Restkostentarif →, private health insurance only covers the remaining share. The benefit areas are the same as in a comprehensive plan, and the premium is lower accordingly.