Appealing a decision by a health insurance provider
Health insurance holders do not have to always accept the decisions made by their insurance provider. If their claim for benefits is rejected, they are entitled to lodge an appeal. These appeals are often successful. It is important that the appeal is well grounded and that deadlines are observed.
At a glance
- If their health insurance provider rejects a claim for benefits, health insurance holders are entitled to lodge an appeal against this decision.
- Appeals must be submitted to the health insurance provider within one month of the insurance holder being notified of the provider’s decision to reject the claim. Providing detailed reasons for the appeal increases its chances of success.
- If the appeal is also rejected, insurance holders can bring a complaint before the Social Court (“Sozialgericht”).
- Advice centers are available to answer any legal questions relating to claims and appeals processes.
What can I do if my health insurance provider rejects my claim?
Health insurance holders are entitled to lodge an appeal against decisions by their health insurance provider – for example, if the provider rejects a claim for specific benefits.
Many benefits – for example for doctor’s visits – are paid by means of the electronic medical data card (eGKO). This is the smart card issued by the health insurance provider, which insurance holders have to present when attending their doctor’s practice.
Many other benefits – in particular relating to aids and therapeutic products, rehabilitation, health cures, travel expenses and psychotherapy – have to be claimed separately from the health insurance provider.
As health insurance providers are obliged to operate in a cost-efficient manner, they check each claim carefully to determine whether the benefits are genuinely required for medical reasons and due to personal life circumstances.
The insurance provider will provide written notification of its decision to approve the claim (Yes) or reject it (No). This is also known as a notice of approval or rejection.
It can be worth appealing a notice of rejection as, in many cases, the benefits are ultimately paid either fully or in part. For this to happen, the insurance holder must provide a specific reason why the claim is essential to them.
If the appeal is also rejected by the insurance provider, insurance holders can bring a complaint before the Social Court (“Sozialgericht”).
What needs to be included in an appeal?
If you want to submit an appeal against a decision by your insurance provider, it’s important to consider the following:
- form and delivery method
- justification (reason for your appeal)
- supporting documents
All appeals must be lodged within one month from the date on which you received notification that the insurance provider had rejected your claim. For example, if you received the letter from the insurance provider on 13 October, your letter of appeal must be received by the insurance provider by no later than 13 November of the same year. If 13 November happens to fall on a weekend or a public holiday, the deadline moves to the next working day.
Important: The deadline refers to the date by which the insurance provider must receive your letter of appeal, rather than the date on which you send the letter.
Form and delivery method
You can choose to mail a written appeal to your insurance provider or to make the appeal orally and in person at any local branch of the insurance provider.
If is important that you sign your letter or the recorded minutes of your oral appeal by hand.
In case there is any dispute, you should send your appeal by registered mail as proof that you submitted it on time.
Justification (reason for your appeal)
To meet the deadline for submitting an appeal, it is sufficient to state your reason for appealing the provider’s decision in a single sentence formulated as you see fit.
Providing a reason for your appeal isn’t mandatory – but it does increase your chances of success. You are permitted to submit the reason for your appeal at a later date only if you would otherwise be unable to meet the deadline for lodging an appeal.
Important questions include:
- Why do you believe that you are entitled to the benefit? Be specific about your personal circumstances.
- Which arguments used by the provider are incorrect?
- Which circumstances may have been forgotten or which supporting documents may not have been given sufficient consideration given their importance from your point of view?
- Are there any comparable court decisions that you could draw on to help argue your case?
If the health insurance provider has specified no reason or only a general reason for rejecting your claim, you are entitled to apply for access to your file. Decisions made by health insurance providers are often based on an assessment by the Medical Review Board (“Medizinischer Dienst”), which you are entitled to request.
If you know the reason why your claim was rejected, it’s usually easier to argue against this or to point out that sufficient consideration may not have been given to important documents.
It is also important to state specifically why you are in need of the benefit. Your doctor can provide you with supporting documentation in this regard.
Be sure to support your reasoning with all important medical documents, such as doctor’s reports and hospital reports, test results, medical opinions, etc. Ask your doctor to provide a letter discussing your situation in specific terms.
Important: All decisions by the health insurance provider must provide information about your right to appeal. It must specify how the insurance holder can go about appealing the decision of the provider – in this case by lodging an appeal. If this information is missing, the deadline for lodging an appeal is extended to one year.
What is the process for appeals submitted to health insurance providers?
Once you have lodged your appeal, the health insurance provider may decide in your favor and send you notification that the benefit is to be paid. Alternatively, the provider may uphold its original decision to reject your claim. In this case, it will pass the matter on to the Board of Appeal (“Widerspruchsausschuss”). This happens automatically. The Board of Appeal is independent of the health insurance provider and not subject to any control. It will examine your case again with fresh eyes.
If the Board of Appeal also rejects your appeal, you can then take legal action and appeal this decision before the Social Court (“Sozialgericht”).
It should normally take no more than three months from the date of your appeal for you to be notified of a decision. You can bring an action for failure to act before the Social Court if the health insurance provider fails without just cause to reach a decision on your appeal within the period of three months.
What can I do if my appeal is rejected?
If the health insurance provider upholds its rejection of your original claim despite the appeal, you can bring a complaint against the decision to reject your appeal before the Social Court.
Your complaint must be filed with the court within one month of your being notified that your appeal has been rejected. The notification of rejection of your appeal will contain information about your right to appeal, and this information will specify which Social Court is responsible.
You can bring a complaint before the Social Court without incurring any legal costs. If your complaint is unsuccessful, you will not be obliged to pay anything to the health insurance provider.
You do not need any legal counsel to represent you during these court proceedings. However, if you require legal expertise and are unable to cover the costs of this yourself, you are permitted to apply to the court for legal aid. In this case, the court decides whether the costs will be covered. Lawyers qualified in social law specialize in the types of cases that come before the Social Court.
Important: You can only take legal action if you have received notification that your appeal was rejected.
It can take several months for court proceedings to conclude and a verdict or a settlement to be reached.
More information about bringing a complaint before the Social Court is provided by the Aktion Mensch e.V. organization on the familienratgeber.de portal (in German).
Where can I get advice and support?
Various centers provide advice on legal issues relating to claims for benefits and what to do when a claim is rejected.
Depending on the benefit you want to claim, these include:
- Social advice centers
- centers offering advice on aids and equipment
- care advice centers
- Independent Patient Advice Service for Germany (UPD)
- consumer advice centers
- self-help associations (offering legal advice)
- welfare organizations
If you need support when taking legal action, you can contact a welfare organization or the office of a lawyer specializing in social law.
- Aktion Mensch e.V. Prozesskostenhilfe: Was ist das und wofür brauche ich sie? Aufgerufen 25.07.2021.
- Bundesamt für Justiz. §12 Wirtschaftlichkeitsgebot. Aufgerufen am 27.10.2021.
- Bundesamt für Justiz. Sozialgerichtsgesetz. Aufgerufen am 27.10.2021.
- IGES Institut. Leistungsbewilligungen und -ablehnungen durch Krankenkassen. Berlin 2017.
- Verbraucherzentrale. Ablehnende Entscheidung der Krankenkasse. Aufgerufen am 25.07.2021.
- Unabhängige Patientenberatung Deutschland gGmbH. Die wichtigsten Fragen und Antworten zum Widerspruch. Stand: 13. April 2021. Aufgerufen am 25.07.2021.
- Unabhängige Patientenberatung Deutschland gGmbH. Monitor Patientenberatung 2020. Aufgerufen am 27.10.2021.
Approved by the Independent Patient Advice Service (Unabhängige Patientenberatung Deutschland – UPD) As at: