Laser eye surgery in private health insurance: reimbursement, costs, legal position

Refractive surgery corrects a refractive error permanently. Three methods are common. LASIK is the widespread standard method, LASEK is an option for patients with a thin cornea, and SMILE is the minimally invasive variant. Which method is suitable is clarified in the preliminary examination by the ophthalmologist. This decision is medical and does not belong in an insurance guide.

The amounts are guide values. Laser eye centers often work with package prices that differ from classic billing under the fee schedule. For reimbursement, what counts in the end is a bill broken down correctly under the fee schedule.

The entitlement rests on two pillars. The first is the plan. Comfort plans often name refractive surgery explicitly, partly with a maximum amount per eye, while entry-level plans often exclude it. The second pillar is medical necessity under § 1 (2) MB/KK. A relevant refractive error, a proven intolerance of glasses or contact lenses, or professional reasons that rule out a visual aid support the justification.

The ruling of the Federal Court of Justice of March 2017 (IV ZR 533/15) clearly strengthened the position of policyholders. According to it, a refractive error is an illness within the meaning of the terms even at moderate values. Glasses are not a medical treatment but only a medical aid that does not correct the condition. Insurers may therefore not reject reimbursement only because glasses would be reasonable. The plan question remains. Where the contract validly excludes or caps refractive surgery, the ruling does not help either.

The order decides. First comes the ophthalmologist's certificate of indication with findings and justification, then the clinic's cost estimate. We recommend that you submit both documents to the insurer together and only have the operation after written confirmation of cover. If you have the procedure before the approval, you negotiate afterwards from the weaker position.

In our work with contracts, the most common surprise we see is that policyholders count on a strong plan, but the contract explicitly excludes refractive surgery. The second surprise is more pleasant. Some insurers reimburse a share as a goodwill gesture, because in the long run the procedure saves costs for glasses and contact lenses. The consequence is the same. First read the clause, then ask, then plan.

Since the BGH ruling of 2017, reimbursement no longer depends on a particularly severe refractive error. In the case decided, the values were in the middle of the minus range. What matters is the medical justification in the individual case and the wording of the plan.

Under BGH case law, a general reference to glasses as the cheaper alternative does not hold, because glasses do not treat the refractive error, they only compensate for it. If your claim is rejected, a written objection that refers to the ruling and to the medical justification is worth it.

That is an individual application. If your prescription changes again, the same standards apply as for the first procedure, that is the plan and medical necessity. Many clinics offer their own terms for touch-up corrections, which lowers the amount you apply for.

No, the visual aid component remains unchanged. If you no longer need glasses after the procedure, you simply stop using it. If your eyesight weakens with age later in life, it is available again.