Assumption of costs by the health insurance company

When does health insurance pay for operations?

People with health insurance in Germany, whether statutory or private, are entitled to health treatment in accordance with Article 27 Paragraph 1 of the Fifth Book of the German Social Code (SGB) if it is necessary to recognize an illness, cure it, prevent its worsening or alleviate symptoms. The legislator sets the following requirements for this:

  • There must be an illness.
  • The treatment must be medically necessary.
  • The treatment must be suitable to bring about relief.
  • The treatment must have a demonstrable benefit.
  • The treatment must have a favorable risk-benefit ratio.
  • The treatment must have a better cost-benefit ratio than other equivalent treatments.
  • The cost-benefit ratio of the treatment must be reasonable for all insured persons.

As a rule, patients have to pay for cosmetic surgery themselves, as it is not medically necessary.

How do I apply for reimbursement by the health insurance company?

The application must always be made by the insured person him/herself. The costs must be applied for from the health insurance company before the service is used. The entitlement to reimbursement of the costs of a surgical procedure expires if the application is not submitted. Your individual findings will determine whether the health insurance company will cover the costs of treatment. The Medical Service of the Health Insurance Fund (MDK) decides on this after being commissioned by the health insurance fund.

What deadlines must be observed?

The health insurance fund must decide on an application for benefits within three weeks of receipt of the application. If the Medical Service of the Health Insurance Fund has been commissioned with the examination, the deadline is five weeks. Costs will be refused if the treatment contract is concluded before the expiry of the health insurance company’s decision deadline for the assumption of costs. If there is no notification of a sufficient reason, the service shall be deemed approved after expiry of the deadline.

Doctor shows the patient something on the computer

What the health insurance companies recognize as an illness

When is treatment medically necessary?

Doctors talk to the patient

Which treatments are covered by health insurance?

The health insurance fund only pays for treatment if, among other things, the cost-effectiveness of the treatment has been ensured by the Federal Joint Committee (G-BA) in accordance with Section 106 of Book V of the German Social Code. Only then is the medical service included in the standard valuation scale for services provided by panel doctors (EBM-Ä) and thus paid for.

After breast cancer surgery, for example, retracted and fused scars can remain. The indication of autologous fat injections for the treatment of such scars is described in a guideline of the Association of the Scientific Medical Societies in Germany (AWMF). The AWMF develops fact-based and interdisciplinary guidelines. Nevertheless, breast augmentation after breast cancer surgery using autologous fat injections is not recommended by the Federal Joint Committee (G-BA). For this reason, autologous fat treatment is not covered by health insurance (Hessisches LSG, 31.10.2014 – L 1 KR 197/14).

The G-BA’s recommendation was often only made to a limited extent and many years after scientific studies on the benefits of the treatments had been published. Examples of this include liposuction for lipoedema, autologous fat treatment for wear and tear of the thumb saddle joint and outpatient vacuum treatment of wounds.

What does a refusal to assume costs mean?

If the health insurance company refuses to cover the costs, the following consequences must be expected:

  • The costs of treatment are not covered.
  • A cosmetic operation that is not medically indicated is subject to VAT.
  • The costs of any complications requiring treatment that may result from treatment are not covered (Section 52 (2) SGB V). We therefore advise you to take out follow-up cost insurance for an operation.
  • A certificate of incapacity for work may not be issued.
  • Prescriptions for medicines or remedies may not be issued at the expense of health insurance.

Where can I get a certificate to cover the costs?


Dr. Stéphane Stahl

There are no financial relationships with the pharmaceutical or medical device industries that could have influenced the above text. Any reproduction, even in part, is only permitted for personal use. All texts used on this website are protected by copyright.

Personal advice

We take time for you and offer you customized advice and treatment for your individual result.

Follow us on Instagram

Follow us on

The CenterPlast

CenterPlast GmbH
Bahnhofstraße 36
66111 Saarbrücken

Telefon +49 681 30140055

Opening hours

Mo | Di
08.00 Uhr – 12.00 Uhr 13.00 Uhr – 16.00 Uhr
08.00 Uhr – 13.00 Uhr
08.00 Uhr – 12.00 Uhr 13.00 Uhr – 16.00 Uhr
09.00 Uhr – 12.00 Uhr 13.00 Uhr – 18.00 Uhr
Centerplast in Saarbrücken