Persons with health insurance in Germany, whether statutory or private, are entitled to health treatment under Article 27(1) of the Fifth Book of the Social Code (SGB) if it is necessary to recognise or cure an illness, to prevent it from getting worse or to alleviate symptoms of illness. The legislator sets the following conditions:
In principle, the application must be made by the insured person himself or herself. An application must be made to the health insurance company for the costs to be covered before the service is used. Entitlement to reimbursement of the cost of an operation shall cease if the application is not made. Your individual findings will determine whether the health insurance company will cover the costs of the treatment. This is decided by the Medical Service of the Health Insurance (MDK) after commissioning by the health insurance.
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. In the case of a If you do not agree with the decision, you can 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:
Treatment is necessary when there is a disease that can be effectively treated. The health disorder to be treated must be sufficiently serious or even threatening. A long history of suffering is evidenced by reports of visits to the doctor to determine and treat the complaints. The examination findings and treatment attempts of your doctors (for example dermatologist, orthopaedist, gynaecologist) of the last few years are considered as proof of this.
The health insurance company only pays for a treatment if, among other things, the economic efficiency of the treatment has been ensured by the Joint Federal Committee (G-BA) in accordance with § 106 of the German Social Code Book V. 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:
Please note that if the costs are covered by the health insurance, the aim of the treatment is to alleviate an illness. Justified aesthetic claims are not in the foreground when the costs are covered by the health insurance. Health insurance benefits must not exceed what is medically necessary (SGB V, § 12). Also, the assumption of costs by health insurance companies is usually accompanied by inpatient treatment.
A certificate is a written expert opinion from the objective point of view of the independent expert. With the issuing of an expert opinion comes a high level of responsibility. Issuing 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 highly unethical.
The application for reimbursement is initiated with a specialist’s written opinion after careful examination and photographic documentation. In the opinion, objective medical findings are collected, without taking into account the subjective feelings of the expert. On the basis of his expertise and experience, the question of necessity must be justified in a comprehensible manner. The expert opinion must stand up to scrutiny by the Medical Service of the Health Insurance Fund. Since there are already many court decisions on the question of the assumption of costs by the health insurance company, the MDK reviews the expert opinion according to the standards of precedents.
The detailed examination, the comprehensive medical photo documentation and the written statement with scientific justification are charged according to the German Medical Fee Schedule (GOÄ). The fee amounts to approx. 250,00 € plus value added tax.
Author: Stéphane Stahl, MD, PhD. There are no financial relationships with the pharmaceutical or medical device industries that could have influenced the above text. Any reproduction, even partial, is permitted for personal use only. All texts used on this website are protected by copyright.