Health fund does not respond: when the benefit counts as approved

The health fund must decide on applications promptly. If it does not do so within the statutory deadline and also does not give you a sufficient reason for the delay, the applied-for benefit can count as approved (deemed approval). That is a strong means of pressure.

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Your chances of getting your money back

If the fund does not decide within three weeks (or five weeks if the Medical Service is involved) and gives no sufficient reason for the delay, the benefit can count as approved (§ 13 Abs. 3a SGB V).

A requirement is, among other things, that the applied-for benefit could appear necessary. Case law sets requirements, get in touch in writing after the deadline and expressly rely on the deemed approval.

What you should do now

1
1. Document the application and date
Record when your application was received by the fund, the deadline runs from then.
2
2. Check the deadline
Three weeks without an MD assessment, five weeks with one. Did the fund give you a sufficient reason for the delay in time?
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3. Assert the deemed approval
If the deadline passed without a sufficient notice, inform the fund in writing that the benefit counts as approved, and demand implementation.
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4. Objection / urgent application
If the fund remains inactive, an objection and, in case of urgency, an urgent application to the social court are options.

How to spot the scam

The fund lets weeks pass without deciding or informing.
A blanket 'processing is still ongoing' notice without a concrete reason.
After the deadline it refuses anyway.

Frequently asked questions

What is deemed approval?

A rule under which an applied-for benefit counts as approved if the health fund does not decide within the statutory deadline and gives no sufficient reason for the delay (§ 13 Abs. 3a SGB V). It protects you from endless waiting.

What deadline does the fund have?

Generally three weeks from receipt of the application, or five weeks if the Medical Service is involved. If the fund gives you a sufficient reason for a delay in time, the deadline extends accordingly.

How do I use the deemed approval?

Document the receipt of the application, check the deadline and inform the fund in writing after the deadline that the benefit counts as approved. Case law sets requirements for the deemed approval, in a dispute a social advice service or legal support helps.

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General information for self-help, not legal advice (RDG). In case of a high loss or uncertainty: contact a consumer advice center or a lawyer.