Health insurance company rejects application for benefits: You can do that
The Patients' Rights Act stipulates that health insurance companies must decide on applications for benefits within three weeks of receipt of the application. If the opinion of an expert is required, the health insurance companies must decide on the approval within five weeks.
The essentials in brief:
- Health insurance companies are obliged to set deadlines when deciding whether to approve or deny services
- You can appeal if your application for benefits is denied.
If the opinion of an expert is required, in particular the medical service of the health insurance companies, the health insurance companies have to decide within five weeks after receipt of the application whether the service will be approved. If she cannot meet the deadline, she must inform the insured person in good time and in writing with a reason. If there is no written justification after the deadline, the application for a benefit is only provisionally approved (Az. B 1 KR 9/18/R). Insured persons can then obtain the required service themselves and, if approved, are reimbursed by the health insurance company. However, the fund can also reject the application for benefits after the deadline has expired.
What do I have to consider in the event of an objection?
If you want to defend yourself against a negative decision, you must lodge a written objection with the health insurance company. You have one month to do this after receipt of the notification. First of all, you do not have to justify the objection, you only have to object to the decision. It is important that you refer specifically to the decision and the file number. An objection is only valid in writing. It is best to send it to the health insurance company by registered mail. An objection by telephone or e-mail is not valid.
If the objection has been filed with the health insurance company, it is always advisable to collect individual medical reasons and documents with the help of doctors and to justify the objection in detail.
Due to this objection, a second decision will be issued by the health insurance company. The health insurance company has the option of approving the service with a remedial notice or rejecting it again with a notice of objection.
What do I have to consider when filing a lawsuit?
If the objection is rejected, you can file a complaint with the social court within one month. It is often advisable to involve a specialist lawyer for social law.
If no decision is made on your objection within three months and no objection notice is issued, you can also file a lawsuit (a so-called action for failure to act).
Private patients do not have to go through a formal appeals procedure, but can bring an action before the civil courts within three years of the negative decision. However, it often makes sense to explain your point of view to the private long-term care insurance company again, similar to an objection, and to justify it with medical certificates, etc., because the private health insurance companies usually check their decision again themselves.
It may take some time before the question of whether the health insurance company has rightly rejected the application is clarified.
We recommend sending both the objection and the complaint either by registered mail with return receipt or by fax to the health insurance company or the court. This allows you to prove that the objection or complaint was received within the deadline. You can also submit your claim/objection personally to the court in the presence of witnesses.
Legal proceedings are usually free of charge for those affected (free of court costs). If you hire an attorney, attorney fees may apply. You can apply for legal aid for this. After filing such an application, the court examines whether the requirements are met.
Where can I get further help?
If you need help with a lawsuit, you can contact social organizations such as the VDK or the SoVD. Otherwise, you should consult a specialist lawyer for social law.
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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