Reimbursement in the statutory health insurance: hardly any real benefit

 Pay for treatments yourself and then bill the insurance company: Those with statutory health insurance can also voluntarily choose the private health insurance model. However, there is a risk of costs that you will have to bear yourself. And the election can only be reversed with deadlines.

The essentials in brief:

• For those with statutory health insurance, the so-called principle of benefits in kind applies: in the case of medical services or services from other health professions, the health insurance company directly bears the costs for its insured persons.
• Instead, you can opt for reimbursement from your statutory health insurance company: You will then receive an invoice from the doctor or hospital, which you first pay and then submit to your health insurance company for reimbursement.
• Caution should be exercised here: Statutory health insurance does not reimburse all costs, but usually only covers the costs that would also arise under the principle of benefits in kind. Invoice amounts in excess of this will not be reimbursed.
• The insured person then runs the risk of not being reimbursed for a higher remaining amount.

Benefits in kind principle - the normal case in statutory health insurance

In the statutory health insurance, the so-called principle of benefits in kind applies. Due to the principle of benefits in kind, those insured in statutory health insurance receive medical services without having to make any advance payments themselves.

The service providers, such as doctors, dentists, orthodontists, physiotherapists or ergotherapists, do not settle their services with the patients directly, but with the statutory health insurance companies or the panel doctor associations.

The principle of benefits in kind obliges health insurance companies to ensure adequate, appropriate and economical care for their policyholders, taking into account medical progress.

This works differently in private health insurance than in statutory health insurance. Privately insured people first settle accounts with the service providers and then have their expenses reimbursed by their health insurance company.

Reimbursement procedure - based on the model of private health insurance

But those insured in statutory health insurance can also choose the reimbursement procedure instead of benefits in kind.

The choice of cost reimbursement can be limited to selected areas of care, for example outpatient, inpatient or dental services. The insured receive the services of the doctor or hospital, for example, against an invoice that they submit to the health insurance company. Insured persons who decide to have their costs reimbursed initially pay the costs in advance.

In contrast to the principle of benefits in kind, doctors or dentists then bill according to the fee regulations for doctors (GÖA) or dentists (GOZ). Higher fee rates can be agreed here than those paid by the service providers in relation to the statutory health insurance companies under the principle of benefits in kind.

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The insured are bound by their choice of reimbursement at least until the end of the next quarter.

Statutory health insurance does not cover all costs. A claim for reimbursement by the health insurance company exists at most in the amount of the remuneration that the health insurance company would have to bear if the service was provided as a benefit in kind. The fund can also deduct a maximum of 5 percent from the reimbursement amount for administrative costs.

The insured persons have to pay the additional costs themselves.

It is also important that the so-called service providers, such as doctors or dentists, must inform the insured person before treatment that there will be additional costs for services that are not covered by the health insurance company's obligation to provide benefits, such as costs for individual health services or cost rates that exceed the service framework exceed statutory health insurance and are to be borne by the insured person themselves.

Optional tariff Reimbursement: Benefits at extra cost

Statutory health insurance companies have the opportunity to offer their insured optional tariffs. Insured persons can voluntarily opt for such a tariff.

In contrast to the principle of benefits in kind, statutory health insurance companies can offer their insured an optional tariff for reimbursement of costs.

With the reimbursement option, you as the insured person pay the medical bill yourself, as described above, and then submit it to your statutory health insurance company for reimbursement.

Many health insurance companies advertise this optional tariff with statements such as "Treatment like a private patient", "Feel like a private patient without being one?" or "private patient without health examination".

Insured persons who opt for such a tariff would like to use the advantages of a private patient for medical treatment, such as faster appointments or free choice of doctor, even with doctors who are not licensed by health insurance companies.

In such optional tariffs, health insurance companies can reimburse you for higher costs than are normally covered by statutory health insurance, so that you pay less yourself for private treatment. However, for these "variable reimbursement tariffs", the health insurance company will charge you an additional premium over and above the normal health insurance contribution.

This premium may be higher or lower depending on the amount of the reimbursement or your age, so that the savings may be lost again.

Reimbursements for treatments abroad

Reimbursement for treatment abroad is a special case. Insured persons can also receive medical treatment in other European countries, e.g. for dentures, and in the end have the costs reimbursed by their local health insurance company.

Important: Anyone who decides on a reimbursement tariff from their health insurance company must adhere to a commitment period of at least one year. In very few cases is the invoice amount fully reimbursed in the cost reimbursement option tariff.

But the same applies here: the health insurance company only pays the amount that it would have to pay as a benefit in kind domestically. There are also deductions for administration costs and for co-payments made in Germany.

If treatment that corresponds to the recognized state of medical science is only possible in another European country, the insurance company may cover the entire cost.

For outpatient treatment abroad, always contact your health insurance company beforehand. There are many special cases. Hospital services abroad, for example, may only be reimbursed by your health insurance company with prior approval (of course, this does not apply to emergencies).

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