Free choice of doctor in private health insurance: when it is really free

The difference from the statutory fund lies in the detail. People with statutory health insurance also have free choice of doctor under § 76 SGB V, but only among doctors with a statutory health insurance license. Privately insured people choose from all licensed doctors in private practice, including purely private practices. On top of this comes direct access to specialists without a referral and without thinking in quarters.

Private health insurance is also more generous when it comes to choosing a hospital. The statutory fund refers you to the nearest suitable hospital and passes extra costs on to the patient if you choose another one. Most private plans, by contrast, reimburse treatment in the hospital you choose freely. There are limits for mixed facilities, for example clinics with a health resort character. We recommend that you get written approval from the insurer before stays in such facilities.

A growing number of plans work with the primary care principle. Insured people commit to seeing their family doctor first and get a lower premium in return. If you still go straight to a specialist, the bill is only partly reimbursed, usually at eighty percent. Eye doctors, gynecologists, pediatricians and emergencies are usually exempt.

This trade is legitimate. It just has to be a conscious choice. It becomes a problem when insured people only notice the clause when their reimbursement is cut. Before you sign, one question needs an answer. Is the premium advantage worth the fixed route through the family doctor?

From our work with plans we know that free choice of doctor is rarely questioned when people sign and is valued most in a claim, above all with serious diagnoses, when a second opinion from a renowned specialist is needed. That is exactly when the quality of the factor clause in the plan shows.

In a plan comparison, we recommend asking two questions separately. Does the plan restrict access, for example through the primary care principle? And up to which GOÄ factor does it reimburse? The combination of open access and reimbursement up to the maximum rate is the benchmark against which any savings have to be measured.

Any licensed doctor in private practice, yes. Reimbursement then follows the plan. It is full up to the agreed GOÄ factor, and partial in a primary care plan if the referral is missing. At the dentist, the same freedom applies under the fee schedule for dentists.

Within Europe usually yes, worldwide for limited periods depending on the plan. The plan rules remain the benchmark for reimbursement, partly limited to the costs that would have arisen in Germany. Frequent travelers check the clause on cover abroad separately.

No, you may still see any doctor. The plan steers through the level of reimbursement, not through bans. You pay the difference between full and reduced reimbursement yourself.

You choose the hospital freely, and the doctor on duty there provides treatment as part of the general hospital services. Treatment by a specific doctor of your choice in hospital, by contrast, is an optional hospital service with its own agreement and its own plan clause.