Fertility treatment and assisted reproduction: what private and statutory health insurance pay

Reproductive medicine offers several treatment paths that differ clearly in effort, chance of success and cost. The usual starting point is a couple that has been trying to get pregnant without success for more than a year and in whom the diagnosis finds an organic cause.

Because several cycles are often needed, couples should realistically plan for total costs of €10,000 to €20,000. This is exactly why it pays to look closely at which insurance system covers which share.

Statutory health insurance pays under § 27a SGB V and ties its share to strict conditions. The couple must be married, the woman between 25 and 40 years old, the man between 25 and 50. Only the couple's own egg and sperm cells may be used, and a doctor must confirm sufficient chances of success.

If the conditions are met, the statutory health insurance fund pays half of the costs for a maximum of three IVF or ICSI attempts, or for inseminations according to the treatment plan. From the fourth cycle, couples pay all costs themselves. On top of this come the usual patient charges for medication. If you are unmarried or above the age limits, you get nothing from the statutory fund and pay everything yourself.

Private health insurance asks a different question. It does not ask whether there is a marriage certificate, but which partner has the illness. Organic infertility is an illness within the meaning of the insurance conditions, and its treatment is medically necessary treatment under § 1 (2) MB/KK. If the cause lies with the privately insured person, their plan reimburses the treatment under the cause principle, including the treatment steps on the partner's body.

The Federal Court of Justice has set the standard for the chance of success. There is a duty to reimburse if the probability of a pregnancy is at least 15 percent per attempt (judgment of September 21, 2005, IV ZR 113/04). Private health insurance has no rigid age limits. In practice, the probability of success takes over this role, because it falls with increasing age.

A limit of three attempts does not exist by law either. Limits are set only by the individual plan. Some contracts contain caps on amounts or numbers of attempts, and some entry-level plans exclude fertility treatment completely. Reimbursement therefore depends on the plan, not on the insurer, and this is exactly where the cost question is decided, long before the first appointment at the fertility clinic.

If one partner has statutory and the other private health insurance, two logics meet. On one side is the body principle of the statutory fund, on the other the cause principle of private health insurance. If the cause lies with the privately insured partner, their insurance covers the entire treatment, including the steps on the body of the partner with statutory insurance. For the couple, this is the most favorable situation, because full reimbursement becomes possible.

If, on the other hand, the cause lies with the partner with statutory insurance, their fund pays only half of the measures on its own insured person and only within the limits of § 27a SGB V. The treatment steps on the privately insured partner often remain uncovered without a diagnosis of their own. So it is not the marriage certificate that decides how costs are split, but the diagnosis, and this is why a complete diagnosis of both partners belongs at the start.

Regardless of the insurance system, the federal government and several federal states support fertility treatment with subsidies, among them North Rhine-Westphalia, Lower Saxony, Hesse and Saxony. The programs noticeably lower the out-of-pocket share of the first attempts and, depending on the state, are also open to unmarried couples. Remaining own costs can be claimed for tax purposes as extraordinary expenses, above the reasonable personal burden of 1 to 7 percent of income.

A special case is switching to private health insurance when you already want to have a child. The health questions ask about planned treatment, and fertility treatment that a doctor has already advised regularly leads to a benefit exclusion or to rejection of the application. From more than 5,000 applications with health questions, we know that timing decides on insurance cover here.

We recommend that you tackle the switch to private health insurance before the first medical fertility diagnosis and test your chances of acceptance in advance with an anonymous risk enquiry. We also recommend that you answer the health questions completely. A concealed diagnosis puts your insurance cover at risk far beyond the fertility treatment.

Yes. Unlike the statutory fund, private health insurance does not require a marriage certificate. What matters is that the organic cause lies with the insured person, that the treatment is medically necessary and that the chance of success reaches the standard of at least 15 percent.

There is no statutory upper limit. As long as each further attempt has a probability of success of at least 15 percent and the plan contains no limit of its own on attempts or amounts, the treatment remains reimbursable. The specific limit is stated in the plan conditions.

Both systems cover freezing egg or sperm cells before a treatment that damages germ cells, for example chemotherapy, including storage. The basis is the medical indication. There is no lower age limit for this.

Only if the method would also be permitted in Germany. Egg donation or surrogacy, which the Embryo Protection Act prohibits in Germany, therefore remains unreimbursed even when treatment takes place abroad and must be paid for entirely yourself.