Principle of needs coverage: what private health insurance actually reimburses

Statutory health insurance has a clearly defined catalog of benefits. What is in it is reimbursed, what is missing is not. Private health insurance works differently. Here the principle of needs coverage applies: what is medically necessary and agreed in the contract is reimbursed. There is no complete list for this, but a review of each individual case.

At first this sounds like a disadvantage, but in practice it is often the opposite. Privately insured people can be reimbursed for benefits that are not in the catalog of the statutory health insurance fund if a medical need can be proven. New treatment methods, special diagnostic procedures or individually adapted forms of therapy can fall under the principle of needs coverage in this way, before they are even listed in the statutory system.

The wording of the plan, however, remains the decisive framework. Not every plan covers the same types of benefits. Dentures, an alternative practitioner or certain check-ups are included or excluded depending on the plan. The principle of needs coverage defines the principle, the plan defines the scope. When you take out a policy, the premium and the insurer are therefore not the only things that count. Above all, the exact scope of benefits matters.

The most common point of conflict is a different assessment of medical necessity. The treating doctor considers a benefit necessary, the insurer sees it differently. In such cases, the insurance contract comes first. If it does not give a clear answer, expert opinions or external experts can be brought in.

An example: dental treatment with high-quality materials is reimbursed if the plan includes dentures and the treatment is medically indicated. Whether a premium implant is reimbursed in full or only a standard replacement depends on the plan, not on the principle of needs coverage alone. Inpatient treatment, rehabilitation and psychotherapy in particular regularly lead to discussions about necessity. A written medical justification that documents the medical need matters more here than a verbal recommendation. Cosmetic procedures without an objective medical reason, on the other hand, do not fall under the principle and are usually not reimbursed.

It is important to distinguish it from the reimbursement principle. The principle of needs coverage determines which benefits can be reimbursed at all. The reimbursement principle governs the formal route, meaning how you submit bills and get reimbursed. The two principles work together, but they are separate concepts.

We recommend that you obtain a written confirmation of cover from the insurer before planned or expensive procedures. The principle of needs coverage gives the insurer room for interpretation on the question of necessity. A confirmation in advance gives you certainty for planning.