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.
What the health insurance companies recognize as an illness
According to the Federal Social Court, health insurance companies are obliged to provide benefits if the physical abnormality is significantly pronounced or disfiguring. In other words, the feature must “constantly attract a lot of attention when passing by” and “cannot be covered by normal ready-to-wear clothing”. In the following cases, it is highly likely that costs will be shared:
- Pronounced fat aprons after massive weight loss with skin inflammation, restrictions in mobility or independent personal hygiene.
- Excessively large breasts of considerable size with persistent skin eczema in the breast folds, painful bra lacerations in the shoulder area or posture-related spinal damage.
- Disfiguring protruding ears in children, if there is a significant impairment of quality of life due to teasing.
- Eyelid corrections for visual field restrictions.
When is treatment medically necessary?
Treatment is necessary if there is a disease that can be treated effectively. The health disorder to be treated must be sufficiently serious or even threatening. Many years of suffering are evidenced by the reports of doctor’s visits that have taken place to diagnose and treat the complaints. Your medical history, in which the examination findings and treatment attempts of your doctors (e.g. dermatologist, orthopedist, gynecologist) of the last few years are documented, serves as proof of this.
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.
Rejected assumption of costs – what to do?
If you do not agree with the decision, you can lodge an appeal in writing within one month. If you receive a rejection notice, you can take legal action and file a complaint with the social court. We recommend that you weigh up these steps carefully with your legal expenses insurance and a specialist lawyer for medical law. As part of the procedure, it is generally necessary to clarify a) whether there is a “pathological disfigurement” within the meaning of previous judgments (BSG, 10.02.1993 – 1 RK 14/92, 20.06.2005 – B 1 KR 28/04 B, 28.02.2008 – B 1 KR 19/07 R), whether b) the treatment is medically necessary and c) whether the treatment method is recognized by the Federal Joint Committee (G-BA).
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.
What does health insurance cover mean?
Please note that if the costs are covered by health insurance, the aim of the treatment is to alleviate an illness. Justified aesthetic claims are not the primary consideration when it comes to health insurance coverage. The benefits provided by your health insurance may not exceed what is medically necessary (economic efficiency requirement §12, SGB V). As a rule, health insurance companies will cover the costs of inpatient treatment.
Where can I get a certificate to cover the costs?
A certificate is a written expert opinion from the objective viewpoint of an independent expert. Issuing an expert opinion comes with a high level of responsibility. Issuing incorrect health certificates against better knowledge is a violation of the professional code of conduct and a violation of the German Criminal Code (StGB, § 278). Furthermore, issuing incorrect certificates is highly unethical.
The application for assumption of costs is initiated with a written statement from a medical specialist following a thorough examination and photo documentation. Objective medical findings are recorded in the opinion, without taking into account the subjective feelings of the expert. The question of necessity must be comprehensibly justified on the basis of his expertise and experience. The expert opinion must stand up to scrutiny by the Medical Service of the health insurance funds. As there are already many court decisions on the question of whether the health insurance fund will cover the costs, the MDK reviews the expert opinion according to the standards of precedent cases.
The detailed examination, the evaluation of all preliminary findings, the comprehensive medical photo documentation and the written statement with scientific justification are billed in accordance with the German Medical Fee Schedule (GOÄ). Plan at least one hour for an expert examination and bring all previous findings with you. A private report is issued in accordance with para. 85 GOÄ 6-fold rate (€ 174.86 per hour) plus VAT and writing fees. The time required to prepare an expert opinion depends on the issue and is at least 6 hours.
AUTHOR
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.
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