Rehabilitation and health resort stays in private health insurance: reimbursement, requirements, practice

Reimbursement of rehabilitation in private health insurance follows no fixed catalog. Under § 192 VVG, the insurer owes exactly the benefits agreed in the plan. For rehabilitation measures, the range goes from full coverage through fixed maximum amounts to a complete exclusion of health resort stays.

Pay attention to the terms in the insurance conditions. Whether they say follow-up rehabilitation, medical rehabilitation or inpatient and outpatient preventive health resort stay decides the scope. Some plans limit rehabilitation benefits to fixed budgets over several years. All amounts mentioned are guide values. What counts is your own plan.

There is a simple rule of thumb for plan quality. A good plan covers daily rates for rehabilitation of at least €300 and names follow-up rehabilitation explicitly. Plans that only list rehabilitation as a discretionary benefit after prior approval shift the risk to the policyholder.

Before any reimbursement, the private insurer checks whether another body is responsible first. If it is about keeping your ability to work, this is usually the Deutsche Rentenversicherung. After accidents at work and for occupational diseases, it is the employers' liability insurance association. For civil servants, the Beihilfe (i)BeihilfeThe state healthcare allowance for civil servants. The Beihilfestelle pays a fixed share of medical costs, the Beihilfesatz, and private insurance covers the rest.More about Beihilfe → contributes. Only after that does your own plan apply.

There is one important exception where private health insurance is the primary payer for rehabilitation. Self-employed people and members of professional chambers with a Versorgungswerk who do not have enough contribution periods in the pension insurance usually have no entitlement to rehabilitation benefits there. For lawyers, doctors or architects, the plan therefore becomes the only cover for rehabilitation. This group in particular should compare the rehabilitation clauses very carefully before taking out a policy.

The application starts with the treating doctor, who certifies the medical necessity and justifies the indication. With this prescription, the planned facility and a cost estimate, the application goes to the insurer. We recommend that you submit the rehabilitation application to the insurer at least four weeks before the planned start. Otherwise there are delays in approval.

The facility determines the costs. As a guide:

• daily rate depending on the facility and type of treatment: €100 to €500
• three-week course of treatment: typically €2,500 to €5,000, highly specialized facilities more
• psychosomatic rehabilitation: often five weeks, extended review and longer processing time

In most plans, you can choose the clinic freely. Some plans work with lists of clinics.

If you plan a health resort stay through private health insurance, you also need a clear indication. Insurers regularly reject purely preventive stays without a medical reason. Health resort daily allowance insurance or health resort cost insurance can close this gap as an add-on.

There are two ways of billing. Many rehabilitation clinics bill the insurer directly after the confirmation of cover. Otherwise you pay in advance and submit the bills. Incidental costs such as travel and the local spa tax remain an out-of-pocket share in most plans and belong in your planning.

From our ongoing support of clients, we see that the most common point of dispute with rehabilitation and health resort stays is a late application. Once the course of treatment has started, no insurer reimburses without prior approval. We recommend that you wait for the insurer's written confirmation of cover before you start, even if your preferred date is pressing.

If the insurer rejects the application, it is worth filing an objection within the deadline set in the insurance conditions, backed by an additional medical statement. If the answer is still no, the Ombudsman for Private Health and Long-Term Care Insurance is available as a neutral arbitration body. In practice, rejections often fail because of incomplete documents, not because of the medical necessity itself.

Yes, if the insurance requirements are met, for example enough contribution periods. Having private health insurance does not automatically mean having no entitlement from the pension insurance. Employees continue to pay into it. The pension insurance decides on responsibility in each individual case.

An add-on that pays a fixed amount for every day of a health resort stay, regardless of the actual costs. It supplements plans that do not reimburse health resort stays or only to a limited extent. The alternative is health resort cost insurance, which pays actual bills up to a maximum amount.

In statutory health insurance they are a mandatory benefit. In private health insurance, by contrast, they are only reimbursable if the plan names them explicitly. Many plans do not. Families concerned should check the plan before planning and, where relevant, include the Beihilfe or the other parent's plan.

As long as there is a medical necessity. Typical stays last three weeks, and five weeks or more for psychosomatic indications. Extensions are possible if the treating doctor in the clinic justifies the further need and the insurer agrees to the extension. Here too, approval must be obtained before the extension, not afterwards.

Often yes, as an extraordinary expense, provided the medical necessity is proven and the reasonable own burden is exceeded. This does not replace reimbursement, but it noticeably reduces the out-of-pocket share. How premiums and costs you pay yourself can be deducted for tax purposes is a detailed question for your tax advisor.