Cost assumption at PKV not at will

Verdict: Private health insurance requires clear criteria for reimbursement

18/01/2012

The private health insurance companies have much more freedom in terms of the selection of their insured persons and the determination of contribution rates as statutory health insurance. But when taking over treatment costs and the private health insurance can not decide at will.

The private health insurance companies must determine clear criteria on the basis of which the insured can understand the regulation of reimbursement, so published on Tuesday judgment of the Palatine Higher Regional Court (OLG) Zweibrücken (file number: 1 U 78/11). The court upheld the position of a private insured who had filed a lawsuit against the refusal to reimburse his health insurance for artificial insemination.

Comprehensive criteria for reimbursement required
In the specific case, the private health insurance of the plaintiff had refused to cover the cost of artificial insemination measures on the grounds that its general conditions of insurance stipulated that the insured person should have obtained a commitment to cover the costs of the insurance before the treatment. In the general conditions of insurance, however, there were no comprehensible criteria on which the insured can determine how the insurance company is checking for reimbursement, according to the charge made to the insurance company in the current OLG judgment.

The rights of insured persons are strengthened
The judges decided that even private health insurance companies should not decide at will whether certain treatment costs are taken or not. If, as in the current case, no comprehensible criteria for checking the reimbursement of costs are mentioned, this uncertainty is borne by the insurance company and it must bear the costs of treatment, the district court of Zweibrücken ruled. The rights of the insured are thus significantly strengthened by the current verdict. (Fp)

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Picture: HHS