Healthcare How to object to a health insurance fund decision

Health insurance holders are entitled to lodge an objection against decisions by their statutory health insurance fund – for example, if the health insurance fund rejects a claim for a specific insurance benefit.

Statutory health insurance funds are billed directly for many health service that they cover (such as doctor visits) by means of the electronic medical data card (eGKO). This is the smart card issued by the health insurance fund, which insurance holders have to present when attending their doctor’s practice.

However, insurance holders are required to submit claims to their statutory health insurance fund for many other benefits, in particular those relating to medical aids, therapeutic services, rehabilitation, health-resort treatments, travel expenses and psychotherapy.

As health insurance funds 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. The benefit must also be appropriate to achieving the objective (for example, recovery). In addition, it must not be unnecessarily expensive.

The health insurance fund will provide 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 objecting a notice of rejection as, in some 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 objection is also rejected by the statutory insurance fund, insurance holders can bring an action before the social court (“Sozialgericht”).

If you want to submit an objection against a decision by your statutory health insurance fund, it’s important to consider the following:

• Deadlines
• Form and delivery method
• Justification (reason for your objection)
• Supporting documents

Deadlines

You have a period of one month in which to lodge an objection. This period begins when you receive notification that your claim has been rejected. Written notification sent by regular post is considered to have been served on the fourth day after it was posted. This means that you can calculate the precise day on which the countdown to the deadline for an objection begins – simply add four days to the date of the post mark.

For example: If the date of the post mark is 9 October, then notification of the health insurance fund’s decision is considered to have been served to you on 13 October. This means that your objection must be received by the health insurance fund by end of day on 13 November. If this date happens to fall on a weekend or public holiday, the deadline ends on the next working day.

Providing a reason for your objection isn’t mandatory – but it does increase your chances of success. You are permitted to submit the reason for your objection at a later date only if you would otherwise be unable to meet the deadline for lodging an objection.

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 health insurance fund 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 fund has specified no reason or only a general reason for rejecting your claim, it may be useful to apply for access to your file. You are also entitled to do so. Decisions made by health insurance funds 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 the benefit is medically necessary. Your doctor can provide you with supporting documentation in this regard.

Supporting documents

Be sure to support your reasoning with copies of 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.

After you have lodged your objection, the health insurance fund will examine your case again. If the health insurance fund decides in your favor, you will receive notification that a decision has been made to approve the benefit. If the health insurance fund decides to uphold its rejection of your claim, your case is automatically forwarded to the Objections Committee (“Widerspruchsausschuss”). The Objections Committee is independent of the health insurance fund. It will examine your case again with fresh eyes.

If the Objections Committee also rejects your objection, you can then bring an action before the social court.

It should normally take no more than three months from the date of your objection 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 fund fails without just cause to reach a decision on your objection within the period of three months. An action for failure to act can force a health insurance fund to reach a decision in relation to the objection. In this case, the social court does not make a decision in relation to the objection itself.

If the health insurance fund upholds its rejection of your original claim despite the objection, you can lodge an appeal before the social court.

Your legal action must be filed with the court within one month of receiving notification that your objection has been rejected. The notification of rejection of your objection will contain information about your right to object, and this information will specify which social court is responsible.

You can bring a case before the social court free of charge without incurring any legal costs. If your legal action is unsuccessful, you will not be obliged to pay anything to the health insurance fund.

You won’t 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.

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.

For those with private health insurance, there is no official objections procedure as in the case of health insurance funds. If a claim for a benefit is rejected by the health insurance fund, you can specify in writing – and with supporting medical documentation – why the benefit is necessary. This should be done as soon as possible. However, an official deadline does not apply as in the case of health insurance fund. If the health insurance fund upholds its decision, you can bring an action before the civil court (“Zivilgericht”) within a period of three years. People with private health insurance can also contact the independent ombudsman for Germany's private health insurance sector (“PKV-Ombusmann”) if they have a dispute their private health insurance fund and apply for an arbitration procedure. This procedure is free of charge and seeks to resolve disputes without court proceedings wherever possible.