Allergy immunotherapy in private health insurance: reimbursement, costs and joining with an allergy

In specific immunotherapy, the body receives controlled, slowly rising doses of the allergen over several years until the immune system tolerates the substance. The method has proven itself above all for pollen and house dust mite allergies and for insect venom allergies. It is not used for food and contact allergies. There are two ways to carry it out.

The first year of treatment is the most expensive because of the dose build-up. The medical fee per injection is modest. Under the medical fee schedule, a single treatment at the 2.3 multiplier costs about €12. Most of the cost comes from the allergen products. In addition, allergy tests beforehand cost about €50 to €150. All amounts are guide values. The ranges depend on the product and the practice.

Not every allergy is suitable for the therapy. It is established for grass and tree pollen, house dust mites and insect venom. For animal hair and mold, it is only used in selected cases. Uncontrolled asthma counts as a contraindication. First the underlying illness is stabilized, then immunotherapy begins. The assessment in each case belongs with the allergist, not in a guide.

Three conditions apply to the reimbursement of allergy immunotherapy in private health insurance. The treatment is prescribed by a doctor and medically necessary, the contract contains no benefit exclusion for allergies, and the allergy either appeared after the contract was concluded or was disclosed in the application and priced in. If these points are met, plans reimburse the therapy as a regular outpatient benefit.

The difference from statutory health insurance lies in the route, not in whether it pays. The statutory health insurance fund also covers allergy treatment when it is medically necessary, but it charges a patient charge of €5 to €10 per product and works with approved products and fixed reference prices. Privately insured people pay up front, submit the bills and have a free choice of product according to the doctor's prescription. For larger sums, it is worth sending a cost estimate to the insurer before the therapy starts.

One detail relieves people with statutory health insurance who have long therapies. If the patient charges exceed two percent of gross annual income, or one percent for the chronically ill, the statutory health insurance fund issues an exemption for the rest of the year. Privately insured people do not have this limit, but because of full reimbursement they rarely need it. If you have agreed a high deductible, however, set the therapy costs against it.

An allergy does not rule out private health insurance, but it changes the terms. In the health questions, the insurer assesses the risk. With mild, well-controlled allergies, acceptance without a surcharge is possible. The most common result is a risk surcharge of about €25 to €80 per month. A benefit exclusion for allergies is also offered, and with severe or uncontrolled asthma, rejection also happens.

Ongoing allergy immunotherapy makes the assessment stricter, because it signals plannable costs over several years and the insurer fears the spread to asthma. Joining is still possible. Some insurers also take over treatments that have already started. Which ones do so at the moment only an enquiry on the market can show.

When you choose between a surcharge and an exclusion, the calculation is clear. A surcharge of €55 over 36 months costs €1,980 and keeps full cover, including for complications. An exclusion saves this amount, but leaves you alone, for example in an anaphylactic shock with intensive care costs of more than €50,000. With allergies, we almost always advise against a benefit exclusion, especially since surcharges can be reviewed on application after years without symptoms.

From more than 5,000 applications with health questions, we know that the order is decisive. Contrary to what is often claimed, private health insurers do not keep a shared register of rejections. A rejection stays on file with the insurer in question. It still makes every further application harder, because open rejections must be stated truthfully there. Direct applications and comparison portals are therefore the wrong first step.

We recommend that people with allergies make an anonymous risk enquiry with several insurers before the formal application, with a current report from the allergist. The report should state the diagnosis, product, course of therapy and prognosis and explicitly record if there is no asthma. The more precise the documents, the better the terms. From the binding responses, you can then choose the insurer with the best assessment. Only then does the application with your name follow.

Then it is a regular insured event. Full reimbursement according to the plan, without a surcharge and without an exclusion. The health questions only assess your condition at the time of application, and new illnesses are covered.

Yes. The pre-contractual duty of disclosure under § 19 VVG explicitly covers ongoing treatments. If you conceal the therapy, you risk the contract being challenged and reimbursements being reclaimed, even years later.

In principle yes, if the treatment is prescribed by a doctor and medically necessary. Because privately insured people are not tied to fixed reference prices, switching between products is also unproblematic, as long as the prescription supports it.

After therapy has been completed successfully and you have had several years without symptoms, it is worth applying for a review of the surcharge. A medical certificate confirming that you are free of symptoms improves the chances. There is no legal right to it, but many insurers review it on goodwill.