When will the costs be covered by the health insurance?

Your individual findings determine whether the health insurance company covers the costs of treatment and any complications requiring treatment. The Medical Service of the Health Insurance Company (MDK) decides on this after the health insurance company has commissioned it to do so.

The health insurance company must decide on an application for benefits within five weeks of receipt of the application. If no sufficient reason is given, the service is deemed to have been approved after the deadline.

If the person concerned does not agree with the decision, he can lodge an appeal in writing. In the case of a rejection decision, the insured person can take legal action and file a complaint with the social court. We recommend that you thoroughly weigh these steps against your legal expenses insurance and a specialist lawyer for medical law. In the context of the procedure it applies as a rule to clarifying, a) whether an illnesswertige distortion in the sense of preceding judgements is present (BSG, judgements of 10.02.1993 - 1 RK 14/92, of 20.06.2005 - B 1 KR 28/04 B and of 28.02.2008 - B 1 KR 19/07 R), and whether b) the treatment is medically necessary.

A rejection by the Medical Service of Health Insurance means:

  • The costs of the treatment are not covered.
  • Follow-up costs that may result from treatment are not covered (§ 52 para. 2 SGB V).
  • Prescription of drugs or remedies must not be at the expense of the health insurance.
  • A certificate of incapacity for work may not be issued.

If there is no medical indication or a participation of your health insurance company in the execution of the planned operation, the conclusion of a follow-up cost insurance is urgently recommended.

Application for reimbursement of costs according to § 13 Sozialgesetzbuch V (Social Security Code)

The benefits of the statutory health insurance schemes are described in SGB V. According to § 27 para. 1 SGB V, insured persons with statutory health insurance are entitled to medical treatment if it is necessary to recognise or cure an illness, to prevent its worsening or to alleviate symptoms. The costs of other services may be reimbursed for medical reasons. In such cases, insured persons must inform their health insurance company in advance or apply for reimbursement. This applies in particular to the following operations:

  • Pronounced aprons of fat after massive weight loss with skin inflammations, restrictions of mobility or independent body care.
  • Excessively large breasts of considerable size with persistent skin eczema in the breast folds, painful bra cords in the shoulder area or postural spinal damage.
  • Distorting protruding ears in children when there is a considerable impairment of the quality of life due to teasing.
  • Eyelid corrections for visual field restrictions

As a rule, the application is initiated with a specialist written statement after careful examination and photo documentation.

The examination, photo documentation and written statement are in accordance with the Section 85 of the Rules on Fees for Physicians (GOÄ). The fact that the fee falls below the GOÄ single rate is not permitted under the law on fees and constitutes a violation of the law against unfair competition (UWG). The fee amounts to approx. 50.00 €.

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Your Centerplast team around PD Dr. Stéphane Stahl and dr. Adelana Santos Stahl is happy to advise you.

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