PKV Full reimbursement for Hartz IV recipients

Privately insured recipients of Hartz IV benefits are entitled to PKV contributions in full

18/01/2011

So far, the job centers refused to pay the full cost of a private health insurance (PHI) for recipients of Hartz IV benefits. Only the minimum rate of the statutory health insurance was taken over. The Federal Social Court in Kassel now strengthened the back of those affected. The job centers now have to pay the full cost.

The 4th Senate of the Federal Social Court decided on 18 January 2011 in the procedure B 4 AS 108/10 R that the self-employed lawyer and private health insurance (PKV) plaintiffs in the period of 2009 in the year of the institution of the basic protection for jobseekers Assumption of his contributions to private health insurance may demand in full.

The plaintiff could no longer - as under the legal situation until 31 December 2008 - as a recipient of benefits to secure a living under the SGB II automatically become a member of the statutory health insurance, but had his private health insurance with a contribution charge of 207.39 euros maintained. An explicit regulation on how to offset the outstanding contribution is not found in SGB II.

In this respect, there is a legal loopholes in the sense of an illegal incompleteness of the statutory provisions. The legislative material on the GKV-Competition-Strengthening Act can not be derived from sufficient evidence that the legislature wanted the privately insured relatives of benefits to secure livelihoods under the SGB II deliberately and intentionally wanted to leave them financially unsustainable contribution share. The written motives contained references to an "affordable base rate" and regulations that took into account that ensured that "those affected would not be overwhelmed financially". The further regulatory context also speaks in favor of a gap that is inherent in the law, because contributions for voluntarily insured benefit recipients in their entirety and contributions to private health insurance are taken over entirely in cases in which the need for assistance according to SGB II can be avoided.

Finally, the constitutionally guaranteed subsistence level of privately insured SGB II beneficiaries would be affected if their contributions to private health insurance were not covered by the provider of the basic security. The irregular loophole in the payment of contributions to the private health insurance is therefore - with regard to the outstanding contributions - to close by an analogous application of the rule for persons insured voluntarily in the statutory health insurance. This results in an obligation of the defendant to take over the contributions in full. (Az .: B 4 AS 108/10 R)

Notes on the legal basis:
§ 26 Contribution to insurance premiums
...
(2) For recipients of Unemployment Benefit II or Social Benefit, who are in the statutory health insurance not insurable and non-family insurance and who in case of illness

1. are insured with a private health insurance company § 12 para. 1c sentence 5 and 6 of the Insurance Supervision Act,
2. are voluntarily insured in the statutory health insurance, the contribution is taken over for the duration of the benefit; For persons who would be in need of assistance only through the contribution to voluntary insurance, the contribution will be covered to the extent necessary.

The contribution is also assumed for persons to the extent necessary, who are insured in the statutory health insurance and who would be in need of assistance only through the health insurance contribution.

§ 12 VAG
...
1c) The contribution for the base rate without deductibles and in all deductible levels may not exceed the maximum contribution of the statutory health insurance; ... .If the contribution is paid in accordance with sentence 1 or sentence 3, is it dependent on need within the meaning of the Second or the Twelfth Book of Social Security, the contribution for the duration of the need for assistance decreases by half; the need for assistance must be checked and certified by the competent institution in accordance with the Second or the Twelfth Book of Social Law at the insured's request. If there is a need for assistance within the meaning of the Second or the Twelfth Book of the Social Code for a contribution reduced by the fourth sentence, the competent institution will participate to the extent required by the Second or Twelfth Book of Social Law at the Insured's request, insofar as this avoids need for help. Irrespective of the amount of the contribution to be paid, if there is a need for assistance under the Second or Twelfth Book of Social Security Law, then sentence 4 shall apply mutatis mutandis; the competent institution pays the amount which is also to be borne by a recipient of Unemployment Benefit II in statutory health insurance.

Also read:
New special rules for PKV change
Hartz IV: 13 health insurance companies charge additional contribution
Exemption of additional contributions from Hartz IV
Study: Fear of Hartz IV makes you sick
Health insurance additional contributions: change is worthwhile

Picture: Matthias Balzer