Medical expenses: What the health insurance company paysThe benefits of the health insurance companies are limited. However, they often reimburse more than patients think. What they pay for sick pay, glasses, travel expenses, dentures and getting a second opinion
If an employee is absent for more than six weeks due to the same illness, there is no longer any pay. Then the health insurance company will transfer sickness benefit for up to 72 weeks. It is therefore important to send the certificate of incapacity for work to the insurance company within the first week of illness – preferably by registered mail.
Each further follow-up certificate should also be submitted as completely as possible and without delay in order not to lose any claims. After a total of 78 weeks of incapacity for work, the patient cannot apply for sick pay again until three years after initial diagnosis due to the same illness.
Employer (up to 6. week) 100
Legal cash (7.-78. Adults need visual aids such as glasses. Pay for contact lenses out of your own pocket. Exception: In the case of a visual impairment of more than six diopters or more than four diopters in the case of astigmatism, as well as severe eye diseases, the statutory health insurance funds pay a fixed subsidy.
This is between 10 and 112 euros per lens and depends mainly on the material. Insured persons must always pay for the spectacle frame and possible extras themselves.
For contact lenses there are the subsidies only in medically compelling exceptional cases. Important: A prescription from an ophthalmologist is required to apply, proof from an optometrist is not sufficient.
Under certain conditions, statutory health insurance companies cover the costs of medically necessary trips to the doctor or clinic, for example, for dialysis or chemotherapy.
Good chances are also given to insured persons with a severely handicapped pass with the signs aG, Bl or H. If someone is classified in care degree 3, 4 or 5, the approval is even considered already granted.
The following applies in all cases: Ask and apply beforehand. A small drawback: the usual co-payment is due for each trip. "Outward and return journeys are regarded as separate journeys", says Heike Morris, legal director of the Independent Patient Counseling Germany (UPD).
10% of the travel costs must be paid by the patient (minimum 5 EUR, maximum 10 EUR)
Sometimes you want to have the diagnosis confirmed by a second doctor, or you have doubts about the recommended surgical method. Everyone has the right to a second opinion, health insurances are not allowed to refuse to cover the costs.
"In the case of uterus removal and tonsillectomies, the doctor must even actively point out that the patient is entitled to a second opinion," says Heike Morris of UPD, says Heike Morris from UPD. The patient always has a free choice of doctor and hospital.
Some health insurance companies also have their own second opinion service. You offer a telephone consultation. Arrange appointments with specialists at short notice.
Survey: "Have you ever sought a second opinion before undergoing a medical procedure??"
Source: Barmer 2019
Dentures are expensive, and health insurers generally cover only half of the costs – with a completed bonus booklet, up to 65 percent. There is a hardship provision for low-income earners: those who do not exceed a certain monthly income limit (see below) can apply for full cost coverage.
This also applies to recipients of social welfare, Hartz IV, basic security in old age, war victims' welfare as well as reduced earning capacity pensions. Who is just above the limit, should ask the fund, then a proportional subsidy is calculated.
The health insurance companies always use standard care as a basis. "Especially in the case of edentulous jaws, this is often not sufficient, we demand better reimbursement here", says VdK-speaker Gierschik.
Income limits for the hardship regulation
single person : 1.246,- EUR
With a relative: 1.713,25 EUR
each additional dependant: +311,50 EUR*
*monthly gross household income
If a patient is unable to manage his or her household due to therapy, the health insurance company will cover the costs of a home help for up to four weeks. If children under twelve years are to be cared for, around which nobody can take care, this applies even up to 26 weeks. For older children, it is worth asking for a goodwill refund. Also ask about the maximum reimbursement per day, which is different for each insurance company. The usual co-payment regulations apply.
Prerequisite: The doctor must ie a certificate stating the beginning, duration and extent of the assistance. "The right exists only if no person living in the household can continue the household", UPD lawyer Heike Morris explains.
A trusted person can also take over the household management. But: For spouses and close relatives up to second degree only loss of earnings and travel expenses (on proof) are reasonably refunded. For some patients, an alternative is up to eight weeks of short-term care in a suitable facility.
It is not always easy for patients with statutory health insurance to get an appointment with a specialist at short notice. The date service places of the cashmedical unions are to provide remedy. The office may take a maximum of one week to give the insured person an appointment within four weeks with a suitable specialist in his vicinity.
Often even within two weeks. Important: There is no entitlement to a preferred doctor, and the insured person requires a referral from his/her family doctor (except for ophthalmologists and gynecologists). Appointments for dentists, orthodontists and physiotherapists are not arranged. If it is more urgent, the medical on-call service can help.
An application for the amption of costs can go through these pa.
© W&B/Dr. Ulrike Mohle
Submit requests for reimbursement in writing in advance. If the application is rejected, it is essential to file a written objection within the deadline. Hannah Gierschik from the social association VdK recommends legal advice: "The objection does not have to contain a reason yet. This can then be handled subsequently by the legal advisor, who has a great deal of experience in this area." Often, the letterhead of a social association or advisor is enough to make an impression, so that the benefit is then granted.