Private health insurance reduces the reimbursement: what you can do

Privately insured people first pay doctor's invoices themselves and submit them for reimbursement. If the insurer reduces it, it often relies on the fee schedule (GOÄ) or the medical necessity. Not every reduction is justified, a medically justified, correctly billed service has to be reimbursed.

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Your chances of getting your money back

The insurer has to reimburse medically necessary services billed correctly under the fee schedule to the agreed extent. Reductions have to be concretely justified (for example a too-high rate factor, a service that was not necessary).

With a justified billing by the doctor (for example special difficulty justifies the rate factor), the reduction is often attackable. You can demand the full reimbursement and ask the doctor for a justification.

What you should do now

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1. Ask for the reason for the reduction
Demand a concrete, comprehensible justification of the reduction from the insurer.
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2. Obtain the doctor's justification
If the reduction is based on the rate factor or the necessity, ask the doctor for a written justification of the billing.
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3. Demand the remaining reimbursement
Submit the justification and demand the remaining reimbursement with a deadline.
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4. Arbitration / ombudsman
If the dispute remains, you can turn to the ombudsman of the private health and long-term care insurance.

How to spot the scam

The reduction is explained only with 'usual rates' without a concrete justification.
A medically necessary service is dismissed as 'not reimbursable'.
It is reduced across the board to a lower rate factor.

Frequently asked questions

May the PKV reduce an invoice?

Only with a concrete justification, for example because a rate factor is not sufficiently justified or a service was not medically necessary. A medically necessary service billed correctly under the fee schedule has to be reimbursed to the agreed extent.

What do I do about a reduction because of the rate factor?

Ask the doctor for a written justification of why the higher rate factor is warranted (for example special difficulty or time expenditure). Submit it and demand the remaining reimbursement. Such reductions are often attackable.

Who can I turn to in a dispute?

To the ombudsman of the private health and long-term care insurance, the arbitration procedure is free for you. For larger amounts, a court clarification is also an option.

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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.