Out-of-pocket costs in private health insurance: your own share and the deductible

Out-of-pocket costs in private health insurance follow the logic of the contract. Under § 192 VVG, the insurer owes reimbursement to the extent agreed in the plan. Wherever this extent ends, your out-of-pocket share begins. The deductible is the chosen, fixed annual out-of-pocket share and therefore the most predictable form. Benefit limits restrict individual benefit areas to annual maximum amounts or reimbursement rates. And plan limits such as the reimbursable GOÄ factor work quietly in the background until a bill exceeds them.

All three mechanisms can add up in the same treatment year. The difference to the deductible in the narrow sense is this. You chose the deductible knowingly and priced it in. The other out-of-pocket costs are in the small print of the plan and only become visible when you make a claim.

From experience, the out-of-pocket share is concentrated in a few areas. The ranges are values from experience and differ considerably between insurers and plan levels.

This is exactly where a cheap plan and a good plan part ways. Low premiums are often bought with tighter limits.

For medicines, private health insurance is more generous than its reputation. Under most plans, prescription drugs are reimbursed in full, without the fixed amounts of the statutory system. Out-of-pocket costs mainly arise for non-prescription products, which many plans exclude or limit.

The most important rule in practice is simple. No prescription from a doctor, no reimbursement. If you accept an informal recommendation for a product instead of getting a prescription, you pay for it yourself.

The myth that private health insurance has no out-of-pocket costs persists, and it is still not true. What is true is that the systems work differently. Statutory health insurance works with small patient charges fixed by law. For medicines, therapies and medical aids, this is usually at most ten euros per item. In hospital, it is ten euros per day for a maximum of 28 days per year. All of this is capped by the burden limit of two percent of income. Its big exception is dentures, where considerable out-of-pocket shares can remain despite fixed subsidies.

Private health insurance has no such flat amounts. Its out-of-pocket costs depend on the individual plan. They are zero in the normal case and much larger in the exceptional case, when the deductible, limits and plan limits come together. In private health insurance, predictability therefore does not come from the law. It comes from your choice of plan and from the confirmation of cover before treatment.

The most common disappointment we see in our advice work is limits that are used up in the middle of the treatment year. The cause rarely lies with the insurer. It lies in a plan that does not fit how the person uses care.

If you often use alternative practitioner services or foresee a need for dentures, we recommend a plan with higher limits or a higher dental scale. The extra premium often pays for itself after one treatment year. When you choose a plan, the risk of out-of-pocket costs belongs on the same level as the premium.

No. The deductible only applies to reimbursable costs. What is not reimbursable at all because of benefit limits or plan limits bypasses the deductible and comes on top. Both items therefore belong separately in your annual planning.

No. The statutory limit of two percent of income only applies to statutory patient charges. In private health insurance, only the plan and the chosen deductible limit the out-of-pocket costs. There is no income-related upper limit.

Only through a plan change to a plan level with more benefits. This counts as additional benefits, and the insurer may ask new health questions for it. The better way is to assess honestly how you will use care when you first choose your plan.