Health Insurance Rejects Your Claim: Here Is What You Can Do

Key takeaways

• Health insurance companies can reject reimbursement for medical costs. However, they must provide a reason for the rejection in writing.
• You can object to the health insurer’s decision to reject your claim.
• If the health insurance provider still sticks with its original decision of rejecting the claim, the case goes to an independent objection committee.
• If the objection committee also rejects the claim, you can take the matter to social court.

This is how you do it

• Never withdraw your objection. Withdrawing your objection means you cannot take any action against the insurer’s decision.
• The health insurer should receive your objection within 1 month from the rejection date. 
• The health insurer must make a decision on your objection within three months.

Table of Contents

The doctor prescribed you a treatment. However, your health insurance company refuses to cover the costs.

You can find yourself in such a situation more often than you imagine. But the good news is you can object to the decision of the health insurer. Moreover, your chances of winning the case are high.

How do you file a claim with your health insurance company?

It’s preferred to avoid situations where your health insurance provider rejects the claims. The best way to avoid it is by filing the claims correctly.

Statutory health insurance companies check if the medical services you request are medically necessary and economical  (Section 12 SGB V). This means that the health insurer weighs two things

• whether you need a treatment
• whether there is a cheaper method available that also achieves the desired result.

The same applies to the private health insurance companies. 

Here is what you can do to avoid rejection.

• Provide good reasons for the medical treatments you are applying for. For example, explain why you need a special wheelchair instead of a standard model.
• Ask your doctors to describe your health state and life situation, specifically in the prescription for the health insurance company. Many times, doctors give a generic reason, which leads to the rejection of the claim.
• Submit as many documents as possible to the health insurance fund to prove that the medical treatment and service are necessary for you.

What is the deadline for the health insurance provider to make a decision about your claim?

• The health insurance company must decide within three weeks of receiving the claim application whether you’ll get the coverage or not.
• The deadline increases to five weeks if the health insurer requests a report from the Medical Service (Medizinischen Dienst, formerly known as MDK).

The medical service prepares the report based on the documents you submitted. However, it can request additional documents or even a personal medical examination.

Deadline for nursing care benefits

If you apply for nursing care insurance benefits,

• the insurance company must offer you advice within two weeks and 
• must decide within 25 working days whether you will receive the benefits or not ( Section 18 Paragraph 3 SGB XI ).

If the health insurance provider exceeds this deadline through its own fault, it must pay 70 € per week to the person in need of care.

What can you do if your health insurance company rejects the claim?

Rejection of medical services by the health insurance companies in Germany is very common. However, you should object to such decisions.

Here is how you do it.

• Write a letter to your health insurance provider.
• Your objection letter should contain the following
  • File number and date of rejection
  • Explain why you need the requested medical services
  • Explain the facts the health insurance provider didn’t consider.
  • Ask your doctor to summarize all medical arguments and put them in the letter.
• You must send the letter to the health insurer by registered post.
• The health insurance company must receive the objection letter within one month from the rejection date.

You can use our sample letter to file an objection.

Tips for successfully objecting to the health insurance company’s decision to reject the claim

• If the health insurance company rejects the claim on the basis of the Medical Service report, you should request the report. If you know the reason for the rejection, it’s easier to counter it in your objection letter.
• Suppose you need more than four weeks to provide detailed reasons for your objection. In this case, you should send a general objection letter within four weeks and mention the following:
  • Inform the health insurer that you’ll provide a detailed explanation or additional documents at a later date.
  • Specify a realistic deadline for when you’ll submit the detailed explanation.

NOTE: Normally health insurance company’s rejection letter mentions your right to object within four weeks. However, if the rejection letter doesn’t mention it, you can object to the decision within one year.

• Request the doctor treating you to explain why a particular medical treatment is absolutely necessary for you.
• If the health insurance company stops paying your sick pay, you should ask your doctor for help and request the doctor to apply for a second opinion.

Suppose your doctor refuses to apply for a second opinion. In this case, list all the doctors who can treat you in your objection letter and add a note:

English – “for the medical justification of the objection, please contact the doctors mentioned in the list.”

German – “für die medizinische Begründung des Widerspruchs wenden Sie sich bitte an die folgenden Ärzte”

If the health insurance company contacts any of the doctors from your list for an opinion, doctors are legally bound to answer.

Of course, they can bill the health insurance company for their service.

What happens after you submit the objection letter to the health insurance provider?

• The health insurance company must re-examine your case and decide whether to approve the claim. This is called a remedy (Abhilfe). 
• If the health insurance company sticks with the original rejection, your case automatically goes to the “Board of Appeal” or “Objection Committee (Widerspruchsausschuss).” 
• The objection committee is an independent committee that has no ties to the health insurance company and reviews your case neutrally.
• The whole case review by the health insurer and the committee must be finished within three months.
• If the committee also rejects your claim, you can take the case to the social court.

NOTE: You can take legal action against your health insurance company only after the rejection from the Objection Committee. 

As per Finanztip’s analysis in 2021, only a third of the objections ended up with the objection committee. The majority of the objections were resolved beforehand because 

• the health insurance provider approved the claim or
• the insured person withdrew their objection.

NOTE: You should never withdraw your objection. If you withdraw it, the objection committee can’t decide on your case. Moreover, you cannot sue your insurer later.

Never withdraw your objection

Health insurance companies use several tactics to make you withdraw your objection. The most common are.

• Approving your claim partially.
• Sending letters stating that you have no chance to win. This practice is not permitted under the German law. You don’t have to reply to such letters.

Under no circumstance should you withdraw your objection. It’s because after withdrawing your objection, you can no longer take action against the insurer’s decision, not even in court. 

Even if the insurer approves your claim partially, you should not withdraw your claim. The objection committee will make a decision on the services not approved by the insurer. So, you have nothing to lose.

NOTE: You should never rely on the health insurance company’s verbal promises. Always get the insurer’s decisions in writing.

What can you do if the health insurance company doesn’t make a decision within the deadline?

Suppose you feel that the health insurance company is

• violating your rights or
• is not complying with the legally required processing deadlines. 

In these cases, you have two options

• Submit a complaint to the responsible supervisory authority.
  • For nationwide health insurance companies, file a complaint with the Federal Office of Social Security (Bundesamt für Soziale Sicherung).
  • For regional health insurance companies, file a complaint with the federal state’s Ministry of Health (Gesundheitsministerium).
• Take the matter to the Social Court.

NOTE: Filing a complaint to the supervisory authority may not help in your individual case. However, you should still file a complaint so that the authorities can check if the insurance company is violating any applicable laws.

Filing a complaint against your health insurance provider in the social court

If the objection committee rejects your appeal, they’ll inform you by sending an objection notice (Wi­der­spruchs­be­scheid). You can then file a complaint with the social court (Sozialgericht) within one month.

You can file a complaint with the social court free of charge. Moreover, you don’t have to hire a lawyer, either.

If you lose the case, you don’t have to pay anything to the health insurance company.

We suggest you hire a lawyer specializing in social law. This will drastically increase your chances of winning. 

However, you must pay the lawyer’s fee yourself. If you have legal insurance, it’ll cover the costs. Additionally, if you win the case, the health insurer will reimburse your legal costs.

You can also apply for legal aid if you can’t afford a lawyer. You can learn more about it in our guide on how to apply for legal aid in Germany.

You should weigh whether the health insurance benefits are worth taking the matter to court. In the worst-case scenario, the court may take several years to decide.

Where can you get support if the health insurance provider rejects your claim?

You can get advice from 

• Independent Patient Advice Germany  (UPD): They offer advice free of charge. 
• Consumer advice centers: They charge a small fee
• Social associations such as the VdK or the Social Association of Germany  (SoVD): The advice is for their members.

The advice centers can support you with the following.

• Tips on how to take action against your health insurance company’s decisions.
• What legal regulations and court rulings could be relevant to your case?

For legal advice, you should look for a lawyer who specializes in social law. Our directory includes English-speaking lawyers who offer services to expats in Germany.

Lawyers in Germany are expensive. Thus, we recommend that expats in Germany have legal insurance to cover the legal costs. 

References

• https://www.finanztip.de/gkv/widerspruch-krankenkasse/
• https://www.verbraucherzentrale.de/wissen/gesundheit-pflege/krankenversicherung/krankenkasse-lehnt-antrag-auf-leistungen-ab-das-koennen-sie-tun-6907