Health and Care Insurance

Health and care insurance while drawing benefits

Health and long-term care insurance are compulsory. Anyone drawing social benefits remains insured: the contributions are paid directly by the authority to the health insurance fund. If the benefits stop, a gap in cover arises quickly.

This gap is treacherous because at first nobody notices it. It only becomes visible when treatment costs arise or contributions are reclaimed retrospectively.

The classic points of dispute

Sickness benefit, the approval of medical aids and treatment abroad are the classic problems with health insurance funds. For treatment elsewhere in Europe the rules of European social security law apply.

Sickness benefit is limited in duration: under Section 48 SGB V it is paid for the same illness for at most 78 weeks within any three years. Disputes regularly turn on whether a supervening illness is the same illness – and on the seamless renewal of the certificate of incapacity for work.

When the health insurance fund takes too long

Under Section 13(3a) SGB V the fund must decide on an application within three weeks, or within five weeks where the Medical Service is involved. If it does not give sufficient reasons for the delay before the deadline expires, the benefit is deemed approved.

This rule is often overlooked in practice. It can rescue a refused application – provided the sequence of events is properly documented.

Disputes about the care level

In long-term care law there are frequent disputes about the assessment. The level of care benefits depends on it. Section 15 SGB XI provides five care levels, determined from total points across six areas of life – from care level 1 at 12.5 points to care level 5 at 90 points.

Where the assessment is wrong, the decision of the fund should be challenged within the deadline. The care diary is often the decisive piece of evidence, because the assessment visit captures only a moment in time.

Frequently asked questions about health and care insurance

What can I do if sickness benefit is stopped?

Lodge an objection immediately and at the same time make sure the certificates of incapacity for work continue without a gap. A gap of a single day can end the claim.

Will the fund pay for treatment abroad?

Within the EU this is governed by Regulation (EC) No 883/2004. Outside it, narrower conditions and frequently a requirement of prior approval apply.

Is it worth challenging the care level?

Often yes. There are considerable differences in benefits between two care levels, and the points assessment can be reviewed in detail.