Private health insurance is an alternative to statutory health insurance, where insured persons have the option of choosing individual benefit packages. An important topic in private health insurance is the reimbursement of costs. In contrast to statutory health insurance, private health insurance does not have any legally defined reimbursements.
Reimbursement in private health insurance depends on the insurance policy chosen and the terms agreed upon. In general, the insurance only reimburses the costs that are expressly provided for in the contract. In the event of illness or accident, it is important to find out about the insurance conditions in detail so as not to experience any nasty surprises.
In the following article, we examine the different types of reimbursement in private health insurance and give you tips on how to achieve maximum reimbursement of your costs.
Basics of reimbursement in private health insurance
Private health insurance (PHI) is an attractive alternative to statutory health insurance (SHI), as it offers more individualized benefits. An important aspect of this is reimbursement, which is handled differently in PKV than in GKV. Here, insureds have the option of paying their own medical expenses and later being reimbursed by their insurance company.
The amount of reimbursement depends on various factors, such as the agreed deductible or the individual tariff. It is usually between 50 and 100 percent of eligible expenses.
The process of reimbursement is usually done by submitting the bills to the insurance company. It is important that all services and costs are listed in the invoices and that these correspond to the reimbursable expenses. It is also important that the services are coded correctly in order to allow for a quick and transparent process.
In addition, it is advisable to find out in advance about the reimbursement policy of one’s private health insurance company in order to be aware of possible restrictions or special regulations. It may also be worthwhile to regularly review your own tariff conditions in order to switch to a better tariff if necessary and thus receive a higher refund.
Requirements for the refund in the PKV
Reimbursement in private health insurance is an important factor for many insureds to reduce their health care costs. Nevertheless, there are some requirements that must be met in order to receive a refund. First of all, it is important that the insured has chosen a tariff with a reimbursement option. This is not the case with all tariffs, therefore one should already inform oneself before conclusion of a contract about it.
Furthermore, there is also a specific reimbursement period in which the bills must be submitted to the insurance company. As a rule, this period is the calendar year and all invoices should be carefully collected and submitted in order to receive the reimbursement in full.
It is also important that the invoices are clear and comprehensible. The costs should be broken down particularly precisely and there should be no ambiguities regarding the services provided. A missing or unclear statement can quickly lead to a refusal of reimbursement.
- Split bills: A split bill is always advantageous to the submitter of a private health insurance policy, as it allows the insurance company to directly see what service was performed for the policyholder.
- Reimbursable maximum limit: Some tariffs have a fixed maximum cost limit for certain services, such as dental expenses. This must be adhered to in order to receive full reimbursement.
In summary, reimbursement in private health insurance can be a complex matter, but one that is of great importance to many insured persons. It is always important to inform yourself well in advance and to know exactly which requirements have to be met for a refund.
Advantages and disadvantages of reimbursement in private health insurance
Reimbursement in private health insurance offers policyholders the advantage that they can be reimbursed for unused services. This can be particularly attractive for healthy insureds with low benefit needs, as it can save them money. Reimbursement can also be an option when changing performance needs to reduce costs.
A disadvantage of the refund in the private health insurance, however, is that in the case of an increased need for services insured may not be sufficiently insured. In addition, it can happen that insured persons regret having chosen reimbursement due to unforeseen events such as illness or accident, since they have to bear higher costs as a result.
- Pro: Savings for healthy insured persons
- Pro: Possibility to reduce costs in the event of a change in the need for services
- Con: Possible shortfall in coverage in the event of an increased need for services
- Contra: Higher costs in case of unforeseen events
It is therefore important that, when choosing reimbursement in private health insurance, insured persons weigh up individually whether the associated advantages outweigh the possible disadvantages.
Reimbursement procedure in private health insurance
In private health insurance, insured persons can receive reimbursement of their medical costs under certain conditions. In contrast to statutory health insurance, where costs are settled directly with the service providers, privately insured persons must initially bear the costs themselves.
After submission of the invoices to the insurance company, an examination of the reimbursement takes place. Costs that are not included in the scope of insurance or excessive invoice amounts may be deducted.
The amount of reimbursement depends on the agreed deductible as well as the private health insurance tariff. A higher deductible can lead to a higher reimbursement.
- Requirements for reimbursement
- Fulfillment of the agreed waiting period
- Submission of original invoices
- Verification of cost coverage by the insurance company
- Procedure of reimbursement
- Receipt of the invoices from the service provider
- Own payment of the bills
- Submission of original invoices to the insurance company
- Examination of cost coverage
- Reimbursement of eligible costs
It should be noted that not all tariffs provide for reimbursement and that some tariffs also have a fixed maximum amount. It is therefore advisable to check the refund conditions carefully before taking out a private health insurance policy.
In general, reimbursement is an advantage of private health insurance, as insureds have cost control and only have to pay for the actual costs incurred.
Summary: Reimbursement in private health insurance
Every year, private health insurance policyholders are faced with the question of a possible refund of their premiums. Unlike in the statutory health insurance (GKV), PKV-insured persons do not receive a regular health insurance reimbursement in the form of premiums.
Instead, some private health insurance providers refund premiums if no or only a few medical expenses were incurred in the previous year.
The amount of reimbursement depends on various factors, such as the tariff chosen and the number of insured persons in the insurance community concerned. There is no guarantee of a refund.
Nevertheless, it is worth comparing the offers of the various private health insurance providers with regard to premium refunds and also paying attention to a possible refund when choosing a tariff.