The benefits of your health insurance, whether statutory or private, must not exceed the level of what is medically necessary (German Social Security Code (SGB), Book 5 (V), Economic efficiency dictates, Article 12). Legally insured persons are entitled to medical treatment in accordance with § 27 paragraph 1 SGB V if it is necessary to recognize a disease, to cure it, to prevent its aggravation or to alleviate symptoms. The costs of other services can be reimbursed if there are medical reasons. In these cases, insured persons must inform their health insurance company in advance or apply for reimbursement. In principle, an application for reimbursement must be submitted to the health insurance company before the service is used. The entitlement to reimbursement of the costs of a surgical intervention expires if the application is not made. Your individual findings will determine whether your health insurance will cover the costs of the treatment. The Medical Service of the Health Insurance Company (MDK) will decide on this after being commissioned by the health insurance company.
The health insurance company must decide on an application for benefits within three weeks of receipt of the application. If the Medical Service of the health insurance company has been commissioned to examine the application, the deadline is five weeks. Cost absorption will be rejected if the treatment contract is concluded before the expiry of the health insurance company’s decision period for cost absorption. If there is no notification of a sufficient reason, the service is considered approved after the deadline has expired.
If you do not agree with the decision, you can lodge an appeal in writing within one month. If the decision is negative, you can take legal action and file a complaint with the Social Court. We recommend that you weigh up these steps thoroughly with your legal protection insurance and a lawyer specializing in medical law. In the course of the procedure it is usually necessary to clarify a) whether a “disfigurement worthy of illness” in the sense of previous judgements is present (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 Joint Federal Committee (G-BA).
In the opinion of the Federal Social Court, the health insurance companies are obliged to provide benefits if the physical abnormality is significantly pronounced or disfiguring. In other words, the feature “in passing” must “constantly attract many glances” and “not be covered by normal ready-made clothing”. In the following cases, it is highly probable that a cost sharing is to be assumed:
The health insurance only pays for treatment if the Federal Joint Committee (G-BA) has made a recommendation on the therapeutic benefit of the method. Only then is the medical service included in the Uniform Assessment Scale for Contract Physician Services (EBM-Ä) and thus paid. After breast cancer surgery, for example, retracted and fused scars can remain. The indication of autologous fat injection for the treatment of such scars is defined in a guideline of the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. (AWMF). The AWMF develops fact-based and interdisciplinary guidelines. Nevertheless, breast reconstruction after breast cancer surgery using autologous fat injection is not recommended by the Federal Joint Committee (G-BA). For this reason, own-fat treatment is not covered by health insurance (Hessisches LSG, 31.10.2014 – L 1 KR 197/14). The recommendation of the G-BA was often limited and many years after scientific studies on the benefits of the treatments were published. Examples include liposuction for lipedema and the outpatient vacuum treatment of wounds.
If the health insurance refuses to cover the costs, the following consequences must be expected:
A certificate is a written expert opinion from the objective point of view of the independent expert. The issuing of an expert opinion is accompanied by a high level of responsibility. The issuing of incorrect health certificates against one’s better knowledge is a violation of the professional code of conduct and a violation of the penal code (StGB, § 278) and is highly unethical.
Author: PD 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 partial, is only permitted for personal use. All texts used on this website are protected by copyright.