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Paying Medical Expenses/Health Insurance Claims in Germany
It can get complicated

The system of payment for medical bills has undergone some minor changes in the past few years. And it is dramatically different for those covered under the government regulated public health insurance system (often referred to as the statutory system) as opposed to those with private health insurance.

Government regulated public health insurance system (Gesetzliche Krankenkasse)

Those insured under the under the statutory system should expect to make small co-payments for a visit to the doctor or when picking up a prescription and even when hospitalized. When visiting the doctor or when being admitted to the hospital you will be required to present your health insurance card (which looks much like a credit card with a chip on it.).

A 10 euro co-pay is normally given to the doctor once a quarter. If you visit the doctor more than once in a quarter year you will only have to pay the first time. If your doctor refers you to another doctor for further treatment or examination, you will normally be given a written referral. When presenting this to the new doctor, you will not have to make the co-payment. If you make a separate appointment and see another doctor without the written referral you may be required to make the co-payment to the new doctor.

There will most likely be some small co-payments that have to be made to a pharmacy when picking up a prescription. This may depend on the type of medication. Most insurers will pay the full amount for generic drugs but there may be additional charges for name brand drugs. Insurances do not normally cover over the counter drugs that are available without a prescription.

For hospitalization a daily fee of 14 euro could be charged. And there are normally some incidental expenses that have to be paid by the patient. (Telephone, TV rental etc.)

Dentist bills are not normally fully covered by the statutory insurance and not all dental procedures are covered. Depending on the insurance you can expect to pay anywhere from 20% to 70% of approved dental bills.

While the patient is responsible for the co-payments and may be responsible for a percentage of dental bills, the health insurance system then takes care of the rest of the bills directly. In many cases you will receive a copy of the bills.

It can get a bit complicated so it is best to consult with the insurer to get the full details regarding the various fees and coverage.

Private Health Insurance (Privat Krankenversicherung)

Many private insurers also issue a card with a "smart chip" on it. In the case of a hospital stay the bill may normally be submitted directly to the private insurer for payment. You'll receive a copy of the bill and may have to pay for some incidental expenses (telephone, TV rental etc.)

Depending on the private insurer, for outpatient services you may have to pay the bill first and then, after submitting it to the private insurer, be reimbursed. Or you may be able to submit the bill to the insurance company and they may pay it directly.

For prescriptions it is normal to pay first and then file for reimbursement.

Doctors, dentists and other health care providers normally send an original as well as a duplicate copy of their bills. And pharmacies will normally ask you if you would like a duplicate copy of your prescription. (The cost of the medications is normally written on the prescription when you pay for it at pick up.) The duplicate bills are a good idea because you will have a copy of a bill after sending the original to the insurance company for reimbursement. If you don’t get duplicate copies, it is a good idea to make a copy for your records.

There are government regulations that stipulate costs for many types of procedures and treatments. However, some health care providers (especially dentists) may offer treatment with costs that are not part of the government regulations. Because of the recent desire to lower medical costs in Germany it is a good idea to check with the private insurer before undergoing any expensive test or procedures to make sure they are reimbursable. Private insurers tend to scrutinize submitted bills more closely these days there is a growing tendency to reject certain requests for reimbursement.

When submitting bills for reimbursement it is a good idea to include a cover sheet listing the date of the bills, the provider’s name and the total amount of the bill. When reimbursement is made the insurance will send you a summary of bills paid and the total amount reimbursed. The reimbursement is normally made by bank transfer. The process may take up to three weeks. If a bill is rejected there is normally a short (and usually unsatisfactory) explanation for the rejection.

If you have submitted a bill that you think should have been reimbursed, but was rejected you can talk to the insurance company and ask for a more detailed explanation for the rejection. You may have to seek your provider’s help to get payment and you may also have to start a run up the insurer’s chain of command to get any satisfaction. The private insurers have set up a fund to finance an ombudsman office that is supposed to operate as an impartial adjudicator of disputed claims, but going through that office can take a very long time before any decision is made. Depending on the company, agents employed directly by an insurer may be of little help in settling these disputes. But it never hurts to ask them how much help they may be able to offer. Independent insurance brokers may provide more help depending on their relationship with the different insurance companies.

Some providers are paid directly and some have an agency that does billing for them.

Some Common Words You May Encounter and What They Mean In English

Abmeldung
deregistration
Angehörige
dependents
Antragsfrist
deadline for application
Beitrag
premium
Beitragsrückerstattung
reimbursement of premiums
Bezugsberechtigter
beneficiary
Berufshaftpflicht
professional indemnity insurance
Betriebskrankenkasse (BKK)
company health insurance fund
Freibeträge
exemptions
Freiwillige versicherung
voluntary insurance
Gesetzliche Krankenkasse
statutory health insurance fund
Gruppenversicherung
group insurance
Haftpflichtversicherung
liability insurance
Hausratversicherung
insurance for household items
Karenzzeit
waiting period
Krankenhausbehandlungen
hospital care
Krankenschein
physician's sick notice
Krankentagegeld
daily sick pay
Krankenversicherung
health insurance
Lebensversicherung
life insurance
Leistung
benefit
Mietrechtsschutz
legal rent protection
Pflegeversicherung
long term nursing care insurance
Pflichtmitglied
compulsory member
Prämie
premium
Rechtsschutzversicherung
legal protection insurance
Reiseversicherungen
travel insurance
Rückversicherung
reinsurance
Selbstbeteiligung
coinsurance or deductible
Unfallversicherung
accident insurance
Versicherungsmakler
insurance broker (represents the client)
Versicherungsvertreter
insurance agent (represents the insurance company)
Vollversicherung
comprehensive insurance