This is how health insurers deal with long-term patients world

Slightly less than half of all long-term sick people have to be examined by the medical service. Every fifth of them is subsequently written healthy

The number of long-term sick people in Germany is rising. But often the insurance companies do not trust the family doctor -. Control even after. For those affected, a new period of suffering can thus begin.

R udolf Meier (name changed) is physically exhausted. The 58-year-old has bad knees. In addition, the former energy plant attendant is troubled by depression. In addition, he has an inflamed intestine, which now forces him back into the hospital.

His wife also suffers from this: "The husband is seriously ill, he can no longer – and I am also at the end of my rope," says Ingeborg Meier. Meier worked for decades at BMW in an Upper Palatinate plant. In the end, they agreed on a settlement. His doctors say Meier can't work.

But his health insurance company sees it differently. According to an expert opinion of the medical service of the health insurance companies (MDK), he can go back to work. He received a letter from his health insurance company: "The determination of your ability to work is justified by the fact that for insured persons who were last unemployed, the ability to work already exists if a light activity can be performed," it states. According to the health insurance company, this includes "museum attendants, porters, telephone operators and mail distributors"."

In short: The insurance company cut off Meier's sick pay. Since then, the couple has been living on the income of their wife, who works part-time for a government agency, and on their savings: "I withdraw 1,500 euros from my account every month," says Ingeborg Meier.

More and more long-term sick

The expert opinion was only drawn up on the basis of records. The 58-year-old was not examined by any doctor of the medical service. The statement covers four lines and concludes that "with existing findings and information" it was determined that "a light activity (. ) was quite possible". All certificates from licensed physicians that Meier submitted were thus ineffective.

Sick pay is generally paid from the sixth week of illness onwards. There are more and more such long-term sick people in Germany. While the average number of people receiving sick pay nationwide was 1.08 million in 2014, the figure had risen to 1.28 million by March 2015.

Expensive therapy – state saves on costs for civil servants

Private health insurance, subsidies from the state: health care for civil servants sounds luxurious. But those who become mentally ill have to pay themselves – or wait a long time for support from the state. In the meantime, the federal government has reacted to the increasing number of sick pay recipients. Lets prepare a special report of the Council of Experts on the Assessment of Developments in the Health Care System by the summer of 2015.

In parallel with the increase in sick pay recipients, the insurance companies now also check more frequently whether the insured person is actually unable to work. The proportion of sick people sent to the MDK by the health insurers has risen rapidly in recent years. In 2010, 36 percent of all sickness benefit recipients were swimming, three years later it was already 45 percent. In all those cases, the health insurer did not trust the treating physician and called in the MDK.

20 percent are written healthy

Correspondingly, the number of appraisals by the MDK increases year after year. Whereas in 2010 there were just under 580.000 appraisals of SHI patients who received sick pay, the number rose to 621 in 2013.000 to. In 2013, this was around 124.000 employees who were originally told by a doctor that they were unable to work.

In 2014, the numbers of challenged certificates of incapacity for work did decline: About 587.000 times, a medical certificate had to be reviewed by the medical service, 17 percent of which were overturned – those affected had to go back to work.

Those affected slip into a problem zone, especially when they no longer receive sick pay, but at the same time a social court hearing is still pending.

However, measures such as the pension at 63, which allows older long-term sick people to slide from the health insurance pots into the pension fund, are also likely to be responsible for the decline. But there were still around 100 last year.000 people on sick leave who had to go back to work despite a medical certificate.

The proportion of those insured whose sick note was declared null and void remained constant. It amounts to about 20 percent over each of the past years.

Health insurance companies remain silent

It is understandable "that the health insurance companies check when sickness benefits have to be paid. After all, we are talking about membership fees and considerable costs here," says Ulrich Becker of the Max Planck Institute for Social Law and Social Policy. The medical service is the right place to go, "even if it is affiliated with the health insurance companies and therefore not completely neutral."

On the other hand, Becker confirms that "those affected slip into a problem zone, especially when they no longer receive sick pay, but at the same time a social court hearing is a long time coming."

The question of whether there are certain health insurance funds that send sick pay recipients to the medical service particularly frequently is a difficult one. The National Association of Statutory Health Insurance Physicians (KBV) has no figures available, according to its own information.

Also the health insurance companies cover themselves in silence. The AOK federal association answers, one does not have "MDK controlling evaluations to the sickness benefit appraisals available". Also with IKK classic, Barmer and technicians health insurance there are no data.

Many don't know about health insurance

The KKH, on the other hand, publishes figures. With it these lie clearly under the average. It is striking that these figures differ significantly from those of the Federal Association of Medical Services. The MDK is also called in by the KKH in about every second case.

However, only six percent of all cases are classified as unjustified, i.e. at least partially fit for work – the number of sick notes across all health insurance funds is around 20 percent. Only in three percent of all cases does the KKH actually stop paying sickness benefits. This decision is in fact up to the insurance companies themselves.

The Association of Independent Patient Consultations in Berlin is frequently confronted with recipients of sickness benefits whose medical certificate has been revoked by the MDK. "Precisely because so many are affected by it, the inquiries also pile up with us", says Jan Bruns patient consultations.

"Often, however, the consultants find that those affected don't even know why they were given a health certificate." Often it is not doubts about the medical assessment of whether someone is fit for work or not, but often it is procedural ies: "If a doctor, for example, does not initiate therapy, then this can lead to the MDKs coming to the conclusion that there is a fitness for work," says Bruns.

Of course, it is also a legitimate concern of the insurance companies, also for economic reasons, to check whether a claim actually exists.

In addition it also happens that the sick note practice of the respective physician is so lax that the MDK indicates fundamental doubts – "the patient can often not know however at all", so the speaker of the patient advisory service.

Request the text of the expert opinion

The advice to concerning is then also: Always request the expert's assessment in the wording, so that one experiences at all first, why it turned out in such a way."In addition, one should "absolutely insist on a therapy and also openly ask the doctor what he intends to do against the disease."

Claudia Schlund is a patient advisor in Nuremberg. She observes that "many of those affected have psychological problems that have arisen because of a situation at work."Often it is bullying, stress and the high workload that have made people ill.

She also confirms that the number of people affected is large – "at the same time, of course, it is also a legitimate concern of the health insurance funds, also for economic reasons, to check whether a claim actually exists."But often those affected "don't even realize at first that their case is being reviewed, only when a legally effective decision is ied that they have to go back to work next Monday, for example."

"Lost faith in the state"

The patient counseling service does not evaluate the particular case – but tries to point out the legal possibilities. "In a difficult situation, it pulls the rug out from under many of those affected," describes Claudia Schlund.

In the meantime, 58-year-old Rudolf Meier has filed a complaint with the social court. The case has been stuck for months now – until it comes to a hearing, Meier will not receive a cent more from the insurance fund.

If the court rules in favor of him, the health insurance company must pay the full sick pay in arrears since March 2014. Whether he believes in it? "I have lost my faith in this state," he says.

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