Dentures and implants in private health insurance: reimbursement, waiting period, practice

The dental benefit limits protect the community of policyholders from major treatments planned at short notice. If you take out a contract and submit extensive dentures shortly afterwards, you only get limited amounts reimbursed. A typical model looks like this. The plan sets the exact values.

Within the graduated limits, the normal reimbursement rate of the plan applies, 50 to 100 percent. The waiting period comes on top of the limits. Under § 197 VVG, the insurer may agree a waiting period of up to eight months for dentures. During the waiting period there is no entitlement, not even a partial one. Many insurers waive waiting periods or drop them after a dental examination. The graduated limits are not affected by this.

For larger dentures, the safe route is the treatment and cost plan. The dentist draws up the plan with the diagnosis, treatment steps, material and a cost estimate under the fee schedule for dentists. You submit it to the insurer and receive the written confirmation of cover with the exact reimbursement rate. Only then does treatment start. At the end, you submit the bill.

The plan is worth it even in cases that seem clear. Most differences do not arise from the rate but from the secondary items. Material and laboratory costs often make up half of the bill for dentures, and plans treat them differently. A confirmation of cover makes these items visible in advance.

Implants are the highest-quality and most expensive form of dental prosthesis. They cost €1,500 to €3,500 per implant, and up to €4,000 with the abutment and crown. There are three variants among plans. Most dental plans include implants and reimburse them like other dentures. Some plans list them as a special benefit with their own maximum amount. A few plans, mainly older ones, exclude implants or limit the number of implants per jaw.

In our advice work, exactly these limits are the most common point of dispute about dentures. The treatment is planned properly from a medical point of view, but the plan caps the number or the material. If you think you may need implants, read the dentures clause for exactly these points before you take out the contract.

A missing tooth that has not been treated counts as a pre-existing condition in the health questions. Insurers usually respond with a risk surcharge or a benefit exclusion for the existing gap. Treatments that a dentist has recommended but that have not yet been carried out must be stated in the application. If you plan to switch to private health insurance, it is best to have open findings treated before the application or to clarify the terms through an anonymous enquiry.

For dentures, we recommend that you check the reimbursement rate, the level of the graduated limits and the implant clause together. A high percentage alone says little. Eighty percent without an accident exception to the graduated limits and with capped implant benefits can be worth less in a real claim than seventy percent with clean clauses.

In many plans, yes. Dentures needed because of an accident are then reimbursed at the full plan rate from the start. This exception is stated explicitly in the terms. If it is missing, the graduated limits apply after an accident as well.

Then the insurer reimburses nothing, not even a partial amount. Treatments that start during the waiting period remain entirely at your own expense. For dentures you can plan, it is therefore worth starting treatment after the end of the waiting period, as long as your dentist considers this medically acceptable.

Only in some plans, mostly in comfort lines and often with their own maximum amounts. The statutory health insurance fund pays for orthodontics for adults only in severe exceptional cases. If you can foresee this need, check the clause before you take out the contract. It can hardly be insured afterwards.