Waiting period in private health insurance: when you receive which benefits

The waiting period in private health insurance is the time after the contract is concluded during which there is not yet full entitlement to benefits. The legal basis is § 197 VVG. Under it, a private health insurer may require a waiting period of up to three months for certain types of benefits, and up to eight months for special types of benefits.

In practice, most insurers apply these periods in full. An exception applies to insured people who switch from existing health insurance without a gap. They can have the previous insurance period credited.

There are two standard periods under § 197 VVG:

• General waiting period (three months): it applies to most outpatient and inpatient benefits. Treatments that become necessary during this time are paid by the insured person, unless they are due to an accident.
• Special waiting period (eight months): it applies to dental treatment, dentures, orthodontics, birth and psychotherapy. Experience shows that these areas of benefits can be planned, which explains the longer period.

For insured people with concrete plans, for example a birth in the first year of insurance or a postponed dental restoration, the timing of the start of the contract is therefore an important factor.

If you fall ill shortly after the contract is concluded and treatment costs arise, you pay them yourself during the waiting period. The health insurer only reimburses after the general period of three months has ended, and for the special areas of benefits after eight months.

An example: if you switch to private health insurance on February 1 and need dental treatment at the beginning of March, you pay the costs yourself. General cover applies from May 1, dental cover from October 1. Emergencies caused by accidents are excluded from this.

The consequences of accidents are the only area of benefits with no waiting period. If you have an accident after the start of the contract, you receive the benefits of your private health insurance from the first day. The condition is that the accident happened after the start of cover.

The distinction is important. The consequences of an illness that happens to appear in the first three months are subject to the general waiting period. Only injuries caused by an external event, meaning the consequences of an accident in the sense of insurance law, are covered immediately.

If you switch without a gap from statutory health insurance or from existing comprehensive health insurance, German previous insurance periods are credited against any waiting periods. This is why many customers already have the agreed cover from the start of cover.

Under § 197 (2) VVG, crediting has one requirement: the new contract must be applied for no later than two months after leaving the previous insurance and must follow on from it directly. If you depend on crediting, for example because dental treatment is planned shortly after the switch, you should get written confirmation before the formal conclusion of the contract.

For benefits with a special waiting period of eight months, the rule is: the start of the contract should be at least eight months before the planned treatment. If you are planning dentures or expecting a baby, you must bring the start of the contract forward accordingly.

Poor planning at this point means that exactly the benefits for which the switch would be most worthwhile fall into the waiting period. This is especially annoying for expensive dentures.

From our advice work, we recommend a transition plan with a buffer of at least four weeks before procedures that can be planned. What matters is to clarify the crediting of the waiting period in writing and to set the start of the contract deliberately eight months before the planned treatment.

The consequences of accidents are insured from the first day of private health insurance. Acute illnesses, by contrast, fall under the general waiting period of three months. The difference lies in the cause: an external accident compared with a physical disease process. In case of doubt, the insurer decides on the basis of the medical documentation.

The periods under § 197 VVG are maximum limits, not fixed requirements. Individual insurers can offer shorter waiting periods in their plans or waive certain waiting periods completely. This is a comparison criterion that should be taken into account in a plan comparison.

A gap has several consequences:

• During this time there is no health insurance cover, and the insured person pays the treatment costs in full.
• With the new insurer, the full waiting period applies, because the transition without a gap that crediting requires is missing.

A benefit exclusion applies permanently to a certain part of the body or diagnosis affected by a pre-existing condition. The waiting period applies for a limited time to all areas of benefits, regardless of your health situation. After the waiting period ends, full cover applies, while a benefit exclusion remains.