Aids - What to do if the health insurance company refuses?

 The health insurance company must decide within a certain period of time about the application for the provision of an aid. You can appeal against a rejection.

The essentials in brief:

• The health insurance company will check whether the requirements for approval of the requested aid are met.
• The deadlines for the health insurance company to decide on the application are regulated by law.
• If the health insurance company does not make a decision by the deadline or rejects the application, you have various options for taking action.

Based on the ordinance for medical aids, the statutory health insurance company checks whether the requirements for the supply of the requested medical aid are met. If this is the case, she will approve the supply of the aid and commission a service provider, for example a medical supply store. You can find more information here. 

Timely decision of the health insurance company 

The deadlines for the health insurance company to decide on the application are regulated by law:

The maximum period for the decision of the health insurance company is 3 weeks . This period is extended to 5 weeks if a statement from the medical service is required. However, the period may not be extended without informing the insured person.

If the health insurance company does not meet these two deadlines, it is obliged to provide the applicant with a sufficiently justified notification. This can be done either in writing or electronically. If the health insurance company does not meet this obligation, the service is deemed to have been approved after the deadline has expired.

Judgment of the Federal Social Court

According to the judgment of March 15, 2018 – AZ: B3 KR 18/17 R of the Federal Social Court, the time limit (3 weeks or 5 weeks if the medical service is involved) does not apply to aids that are used to prevent or compensate for a disability. The judgment applies to a large number of aids.

“Aids from statutory health insurance for prevention and compensation for disabilities are part of the services for medical rehabilitation – unlike services that serve to ensure the success of medical treatment. They are not primarily used with the aim of having a therapeutic effect on the disease, but mainly with the aim of compensating for or alleviating the associated impairment of participation in a person with a disability."

Aids to compensate for disabilities are, for example, prostheses, hearing aids or wheelchairs. These are aids that replace, for example, a body part or a sense that is no longer available.

Aids to ensure the success of the treatment are, for example, support and holding devices for affected parts of the body, bodices and support corsets. They support the body during treatment and thus prevent pain or the progression of an illness. 

According to current case law, a different deadline applies to aids to compensate for disabilities. The health insurance company must decide within a period of 2 months from receipt of the application (statutory regulation: § 18 SGB IX). An extension of the deadline is possible under certain circumstances. Only after this much longer period has expired is the requested service considered approved.

What happens if the health insurance company does not make a decision on time? 

If those entitled to benefits procure the required service themselves after the deadline has expired, the health insurance company is obliged to reimburse the costs. Even if the health insurance company has wrongly rejected the service, a claim for reimbursement of costs can arise in individual cases. 

Basically, the entitlement to aids is a “benefit in kind entitlement”. This means that the health insurance company makes the aid available to the insured person. If, exceptionally, this claim for benefits in kind turns into a claim for reimbursement of costs, this is a special case. If there are problems with the health insurance company, you should seek legal advice .

Tip!

Before you buy an aid yourself, you should carefully consider whether you can pay for it yourself if in doubt. Because subsequent reimbursement of costs is only possible in very limited exceptional situations, you bear the cost risk.

In any case, the consumer advice center strongly advises you to apply to your health insurance company before purchasing the aid. This can only be dispensed with in an absolute emergency.

Negative decision of the health insurance company: objection and lawsuit

If the health insurance company comes to the conclusion after its examination that the requirements for the supply of medical aids are not met, it will reject the application. It communicates the decision in the form of a notice, usually in writing.

How to appeal

An objection is possible against a negative decision . It is important to meet the objection deadline. If the notice contains correct instructions on legal remedies, the objection must be received by the health insurance company within 1 month of receipt of the notice. If there is no instruction on legal remedies, the objection period is 1 year. When calculating the deadline, start with the day you received the letter.

The objection must be submitted in writing . Justifying the objection and making the necessary arrangements with the medical staff takes a lot of time. First of all, a short message to the health insurance company that you do not agree with the decision, to object and to provide a reason is sufficient. It makes sense to send the objection as a registered letter with acknowledgment of receipt or as a fax with acknowledgment of receipt, because this way you can prove timely receipt to the cash register in case of doubt.

Afterwards, however, be sure to provide a reason why you do not agree with the refusal of the provision of medical aids. It often makes sense to ask the prescribing doctor for an opinion and to explain in more detail why the aid is necessary. 

Tip!

Health insurance companies often refuse treatment on the grounds that the aid is not listed in the list of aids. However, your entitlement is not limited to the aids in the list of aids. In the opposition proceedings, explain in detail why this tool is necessary for your individual case. 

In the objection procedure, the health insurance company reviews its decision. Either it comes to the conclusion that the right to the aid does exist and approves the supply. She speaks of a "remedy". Or she sticks with the rejection.

At the end of the objection procedure, the objection committee of the health insurance company advises and issues the objection notice. If the objection decision is still refusal, you can file a complaint with the social court . It is advisable to involve a specialist lawyer for social law.

Where can I get further help? 

If you need help with an objection or a lawsuit, you can contact social organizations such as the VDK or the SoVD. Otherwise, you should consult a social security lawyer. 

Some consumer advice centers offer advice on the subject of aids and support you with legal questions relating to the application for aids and an objection to the health insurance company.

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