Private health insurer won't pay out on a claim

Hello

My private health insurance company are declining/refusing to pay some bills. Actually the bills are for my 3 year old daughter. The bills are from an eye specialist she was referred to by the local eye doctor, and for the local eye doctor too.

Deciphering their message it seems they are saying it's a pre-existing condition - they asked permission to contact the previous insurer and we granted them that permission.

This is true in the sense that the condition was probably present at birth, but was not fully diagnosed until recently. In fact diagnosis was not clear until we saw the very specialist whose bills are being declined! Even now we/they are not clear the extent of the problem.

We changed insurers when our daughter was 1 year old. In that first year we had noticed our daughters eyes moved a lot, a fairly common condition known to us now as nystagmus. In that first year we were told that there was basically little they could test at her age, it's a common condition in young children and often just goes away, and to take her to the eye doctor when she was about 3 or so. This is what we did. Even now, though it's not ideal, neither is it a big deal - my daughter wears glasses and her sight is close to normal. However the specialist has advised that to avoid neck/back issues it's likely she may need surgery later in her childhood, maybe at 6 or 7. She too said "come back next year and we'll know more".

How should I proceed? is there some kind of ombudsman that adjudicates in cases like this? Who controls these firms if they are just unreasonable?

CT

PS: Perhaps it's relevant, but when we changed insurer they asked for a special form to be completed by a heart doctor as my daughter had had a small hole in her heart during pregnancy. That hole had closed up, as they often do, during the later stages of pregnancy, and this was confirmed by another test a few months after birth. The insurer accepted her with that form. We answered all questions posed on the insurance forms honestly and in good faith.

PPS: I had a similar issue many year ago when I had bronchitis, and my insurer (different firm) declined to pay saying that too was pre-existing. It wasn't - I had had no lungs/bronchs problems until my first cold Munich winter! Sure, I had had a cough before. Had I been able to I would have opted out of the private system then and there, but as I've not yet been fired I cannot! Nor, for my sins, can my kids. Buyers beware!

Private insurance is a scam. I had this happen many times when we were on it - you only find out AFTER you pay the bills what they will and won't cover. And that's AFTER the deductible and the ridiculously high premiums. I was lucky and was able to transfer over to the public system.

@gills: How did you switch to public insurance? I was told that it's not possible unless your pay falls under.

@CT: I have a "similar" situation where I am seeking psychiatric treatment. I contacted my private insurance BEFORE seeking treatment and they sent me a bunch of papers to be filled in. They explained that of course, if my psychological problems were a result of a bad childhood for example, that would be covered. They needed a statement from my previous insurer that I had not sought treatment with them THEN and I got this in writing from the previous insurer, not them contacting my previous insurere.

My pay was right on the line when we were sold the policy. When the threshold was increased, I fell just under but had to wait a year before I could switch. My husband was in a worse situation; his contract ended but we had to continue paying the high premiums. Fortunately when I got public insurance he was able to be covered under my policy since he is no longer earning money.

Yes it was a bad decision to get involved in private insurance. Being canadian with absolutely NO experience of health insurance, we were particularly easy targets for an unscrupulous insurance salesman. We didn't know the language and had to rely on what were told, which was that it would be easy to get out of if we wanted. Believe me, the insurance company (and it is well known and supposedly quite reputable) didn't make it easy for us to get out of the policy. We were lucky that a very determined German friend did battle for us, and even she was disgusted by their tactics.

I would never recommend to anyone to take out private insurance. If you're young and it seems cheap, don't be foolish. You'll pay for the mistake eventually.

If the previous insurAnce knew something about the eye then you must have known too. As such you probably should have mnetioned his fact to the new insurance company when you signed up. Seeing as you did indeed know about this condition and you didn't tell hem about it then in his saw you probably shouldn't have given them prmission to contact he othe company - it sounds like this is an optional thing

According to Med-Kolleg, the state insurance premium is around 14% of your income. So if you earn more money, it is better to take private insurance:


In my case, it works out that I pay a much lower premium with a private insurance than the public one and I get half year's premium* returned to me if I do not submit any medical claims for the year.

Most of my ailment is for allergies and "special" treatment e.g. back problem which comes up to 150 Euro or so each time. So that means I can seek an average of 10 treatment in a year without the need to submit the invoices as I will be reimbursed by the premium I get back.

However, I was stupid to send in my claims last year when it was only about 100 Euro more than the premium refund because now, the insurer knows who I go to etc. and is making it a little difficult (i.e. asking for doctors' references) when I'm seeking new treatment.

*My share of the premium

Yes, the premium. When you start counting in the deductibles, the things they won't pay, the things that they'll exclude over time, it won't be 14%. If you lose your job, good luck. We had a hell of time getting out of the private insurance even though the premiums amounted to 37% of our take home pay. The insurance company doesn't care. I still believe that private insurance is a foolish choice and firmly believe that there is NO place for private insurance in the health business. It should be universally banned.

Thanks to everyone who took the trouble to read and respond to my query.

Most have looked at the general public-v-private argument. My own view is private is OK for people who know 100% that they wont be staying in Germany for long, and are in perfect health. Otherwise it's risky, and the arguments that the "care is better" is 99% baloney.


The questions asked when we changed insurance were pretty specific, has your daughter been in hospital for treatment in last year, if so give specifics, and so on. We answered all honestly, giving the information about the heart condition mentioned above. We never saw any eye specialists until recently, and had no inkling of any serious issues (and I repeat, even now it's still very unclear if this will be a serious issue, in the medical sense, or not)

Someone replied that we could not have allowed the insurer to ask questions of previous insurer or doctors. The letter they sent us basically said they could not process our claim without us allowing this, I don't see how we could have said no?

Anyway the "cost" to the previous insurer was about 80 euros or so, for one check up at the local eye doctor who said "bring her back in 2 years".

My core question remains - What/where is the route to appeal, if any?

CT

This seems to be the guy: Ombudsmann

The info is all in German, but he's what it says on the tin and there's no charge for his services (according to the website info).

Hope this helps

The average is 14% combined between employer and employee, so the total is about 7%. It's also capped on the statutory limit for mandatory participation in the public Kassen.

Had a similar deal with ARAG, shower of thieving wankers! Got signed up through Impuls.de (who are supposed to be neutral and fair in their recommendations) a few months down the line ARAG got wind that I had had limes disease in my right leg years ago, although proving to them that it had cleared up through a course of antibiotics they still hiked up my premiums by 30%, saying I had not declared it in my initial application... after that I visited every doctor and dentist I could to take the c**ts for a ride... got a good deal out of them but could no longer afford the premiums after loosing the job.

CT: you should check again the application form you filled out for you/your daughter when you signed her up with the new insurance. A typical question in these forms (which can be found with virtually every insurance provider since the health related questions are organized through their head organisation) is this: " are there any ailments, illnesses or disability you are aware of that have not been treated, are imminent for treatment or recommended for treatment?" If you have checked the "no" - box on this, the insurance will tell you that you should have reported the eye-problem there and then. Because as you mentioned above, the doctors just said that there was nothing they could do about it at this point of time - which means that there is the possiblity that there will be something to be done in the future. You are lucky that they do or did not cancel the insurance coverage right away for which they are entitled if you have not disclosed everything you know at the time of application. Just that the old doctor said: "bring her back in 2 years!" is evidence enough that a potential health problem was evident to you and others, but not reported to the insurance at the time of application.

I know that this is not what you want to hear and there may be a bit of a gray zone there if some doctors would say that this is not exactly a pre-existing condition, but I am sure that the insurance will find other doctors who will say it was and is..

Like I did in the past, I can't stress enough to disclose every treatment or health problems you have had in the past 5-10 years before the application if the health problem and treamtent occured in GErmany or within the EU and/or of the problem is ongoing/not toally solved. It is a bit different in my opinion, if you suffered a health problem in the US, Philipines or whereever outsite of Germany and if the health problem was solved/healed out... some of these problems could still unnecessarrily result in additional health risk premium in Germany, since German insurances are even more paranoid then from what I hear about US insurances.

CT can of course address the "Ombudsman für das Versicherungswesen" but I have my doubts that anything positive will come out of that.

While GILLS had really a very bad experience with the health insurance (I know because we talked a lot about potential options at that time), the conclusions she draws are not entirely waranted and there are enough cases out in the public media where it can be found that public health insurance screwed really ill people around big time until ordered to cease to do so by courts (often when the insured were already dead). There are bad eggs in every basket, I fear, which is exactly why it is so important that someone unbiased and neutral checks out all your options right in the beginning and is there to help you if things go wrong/bad. Private health insurance can be a good or a bad choice, depending on your individual situation, your plans for the future (and how they turn out eventually in reality) etc. Should you ever be ill enough to require treatment by the best specialists, you will see that there are some severe limits to what you can get with the public health insurance.... some of the best doctors will not even accept you for treatment unless you pay privately extra and we are talking big bucks here.
But in general and as I have said in many other threads here, GILLs is right if she says that the German system is screwed up and needs a serious overhaul of the whole system..

Samsung: if the limes desease was healed out or not at the point of time when you applied for the insurance is not the matter. If the relevant health question in the application adressed a period of time backwards in which the health problem happened (usually up to 10 years) that you have to report it nevertheless in the application with the information when it occured and that it is healed out according to you and the doctors ( which the insurance will then certainly check), because it is not your decision but the insurances decision to see this as an additional risk to come back or not.... and obviously some problem came back there, right, otherwise the insurance would not have make it a point that there was some unreported pre-existing condition. So you may have thought it to be healed out and that it would not cause any more problems to you, but there could be a statistical increase in risk for a return of the same or related problems which only the insurance can judge and decide upon correctly.

Cheerio

Hi


Thanks CT for the input.

I think, with respect, you misinterpret the mentality of the people filling in the forms. I simply would not have interpreted my situation as any of "ailments, illnesses or disability". No treatment had been recommended, nor was any imminent. I filled the forms out with a insurance broker (also Impuls as it happens) and he helped us fill the forms in.

On the more general point, I was sold private medical insurance on the "its cheaper and better" line. I read that line a lot here. Not once did anyone ever tell me that my family would also require private insurance later on. Not once was it explained that I could not (easily) get out of the private system if I was unhappy.

It was also a big surprise the first time a doctor bill landed on my doormat - why are they sending this to me I thought? Why are they not sending it to to DKV who I/my employer pay to take care of this stuff? It's only then I learned that *I* would be the paper shuffler in this area. And, frankly, I just don't buy the stuff about get treatment from top docs. IMO it's baloney used to sell insurance.

By the way, are there any league tables published which track how "awkward" PKV insurance companies with claims? any particular insurer got a reputation for being "understanding"?

Kevin

CT: While I can understand your frustration, from what you describe above you simply got poor advice from your broker IMPULS who is a big one offering health insurance advice through all kind of marketing and PR. But the points you mentioned above, like not being told about the consequences of your decision for family members and so on reek of hard-selling instead of good unbiased advice. I,for instance, not only will of course have informed my clients that they'll receive the doctor bills first (which makes a lot of sense if you have an interesting no-claims bonus, because then you can decide to pay small bills yourself and get the no-claims-bonus after one year, for instance). As someone who is specialized in service and advice to Expats (like Mike Woodiwiss from Spectrum here on Toytown and others with similar specialized services spreadall over Germany) I do also offer to help with the claims settlement as part of the service since the commission one gets from these insurances is high enough to warrant such services without extra fees/costs. Unfortunately your bad experience is more the norm then the exception in Germany simply for the reason that the financial advice market has not been regulated like in the UK, Ireland or US to name just a couple of countries of origin of Expats where something like that would cause serious trouble to the person or company who offered bad advice. If you want to read a little bit more about the difference between a really independent broker and the majority of salesmen here in Germany, read here on our own website: http://www.crcie.com/pageID_5814397.html

If you have read my own comments and advice here on Toytown sometimes than you know that I - like any really honest and unbiased broker - constantly make people aware that short term benefits from getting "cheaper" insurance can have dire long term consequences they also need to think about. And of course part of the most basic information to anyone contemplating private vs. public health insurance is that once you made a decision to opt out from public health insurance, the way back is very complicated and mostly totally barred. The following paragraph is a quote from our website with regards to the options for employees to decide between private and public health insurance, just to proof my point:


The full information can be found here: http://www.crcie.com/pageID_5743775.html and, if I am not mistaken, also within the WIKI on health insurance here on Toytown. Potentially, though, this information was not available yet when you made your decision or rather followed in good faith some bad advice?

However I would like you to differentiate between the poor advice you have received from a hard-selling organisation and the benefits in toto a private health insurance can have for a number of people still. Having said that: you personally might not be among the people to benefit from this insurance after all, but that again is the results of bad advice and not of bad insurance.

There is indeed a measurement to see if an insurance is rather fair in claim settlement or if low premium prices are based on constant declining and battling claims. Every good and unbiased broker uses this information when pre-selecting and recommending health insurance after a research of what the market offers for a client. The information can be found at the website of the above mentioned Ombudsman and shows how many disputs about claims etc. are found or reported with each individual insurance company each year and the ratio of the number of existing insurances to disputed claims is an excellent yardstick to differentiate between good and bad insurances.

There is one lesson here in the end, while probably for now your health insurance choice and all related problems can not be dealt with easy and soon: for whatever finance related issues you want or need advice in the future, be that other insurances or pension planning or investment, get yourself help of a truly independent financial advisor of which some advertise here on Toytown and where you can see from the comments of other Toytowners if the advice has been good or not. That does not mean to imply that outside of Toytown there may not be other good advisors, some of which might be living closer to you then me or Jacqui Cummings or Mike Woodiwiss etc. But here on Toytown you can at least find some people who are only still here because they have done a fair job to others on TT, otherwise they would have been crucified publicly here already...

Cheerio and good luck for the future

Hi

Again, despite my "frustration", I do thank you for taking your time to reply.


I'm not sure I really appreciate the distinctions you are making here, reminding me of "the operation was successful, but the patient is dead". Nor do i really buy the "independent" broker stuff. Sure you'll get different advice, and maybe better on the average. But, weighing things up, you'll probably get even better advice here on this forum and the TT archive on this topic. Your industry needs think about that ...

A friend of mine was once a signature away from signing up for PKV, only when I asked if his deafness in one ear was written on the forms did he think twice. "It matters?" he asked innocently? He had been publicly insured, and he'd presumed all medical details had been sent to private firm from AOK/TKK/..., and they had accepted him, so it was a non issue. That's how the market is sold, you can "choose" between public and private - it's like moving bank accounts. I know different, Starshollow knows different. but Joe Foreigner has no idea during his first days or weeks or months ...


Cool. Where can I see that data? I'll wager I can't, it's for "insiders" only? But please correct me if I am wrong?

CT

I ain't found it yet, but if two of us are looking we might find it a bit quicker this is where I'm digging at present.

Maybe Starshollow will look back in and post us a direct link to the relevant site!

No prob, here is the link: http://www.bafin.de/cln_042/SharedDocs/Dow.../st_2007_be.pdf

as you can see, the "Ombusdsmann für das Versicherungswesen" publishes a dispute statistic every year, so that also trends can be recognized and evaluated. It is a 16 page document which covers all the major insurance types, private health insurance can be found on page 3.

So, CT, you lost a wager here, right?

Sorry that you don't believe that there are actually good and honest advisors out there... obviously even my many contributions here on Toytown could not convince you to the contrary. It just will make your life just so much more complicated if you'll try to find out everything by yourself now in order to get it right. But after your recent experience I guess I can't blame ya. You are correct that the industry needs to think a lot about what you mentioned and unfortunately as the latest reforms have shown, the insurance industry is far to strong in Germany and far to focused on the good old ways that they lobbied away successfully many other necessarry reform steps already. Therefore it will take a lot of time before we see the number of German "advisors" reduced to a number equal per capita like in the UK and with a similar change in character and selection of people working as financial advisor. Until then I probably have to live with the bad image financial advisors still have in general in Germany... and try to convince people from an alternative approach of mutal fairness which is to the benefit of all. Trust me: I am not with the Salvation Army, I am running a business BUT I believe that it is to the best of my business success on the long run if I treat my clients fair and square to their best interests. Thus, I am honest because it is good for my business (cunning approach, eh?) and not because I am a "Gut-Mensch". So far this approach works pretty well, even though more often then I like to I have to cloean up the mess other hard-selling individuals have created with my new clients in the past - and being taken advantage of is not something reserved to Expats, Germans fall for that just as regularily as well.

Cheerio

What I learned in Germany about health insurance after 7.5 years here: Do not go for private insurance if you do not REALLY REALLY REALLY know what you are doing.

The advise I got for my employer and colleagues: Just get public insurance and after you really understand the thing you decide if you want to change.

I am still in the public system.

some caution is always advisable indeed when going for private health insurance. If you want to play it safe but also do not want to forgo certain areas of coverage (like head-of-department and 1-bed-room in a hospital or higher coverage for dental replacements) then you can always get yourself some private add-on insurance for reasonable prices. There are a number of cases or scenarios where a private health insurance is definetly the better option, others just as clear where only the public health insurance can be the right solution and then there is a huge grey-zone within these two. Good information or good advice (if you can get it) is paramount to making a good, educated decision.When in doubt, start to go with public health insurance as an employee until you have learned enough to make this decision. As a freelancer you can always start with a coverage-reduced international or special Expat insurance ( for as little as 76.- EUr/month to cover in- and outpatient treatment) for a while before deciding which way to go. KRIEG is very right about that...

Cheerio

Good advice here. I wish I'd known all this when I moved here. There would be thousands and thousands more dollars in my bank account instead of donating it to a bloated and greasy private insurance company.

CelticTiger, i'm not sure if you know this, but it is now possible to get back into the public system. they have to take everyone now. this went into effect in april 2007.

when i started working freelance, i was advised by a friend not to leave the public system, because i ran the risk of never being able to get back into it. this was 4 years ago. as i mentioned, one of the government reforms was to get rid of this situation.

i also opted not to get private insurance because i had a couple of operations here and one of which was major. and i just think virtually any future problem i might have could easily be linked to that and labeled 'a pre-existing condition.'

but CT, next time you have to send your insurance company a form from a doctor speak with the doctor beforehand and explain the situation in great detail. perhaps the doctor didn't have to write that he asked that your daughter return in 2 years. comprendé?

@leylah, I'll wait for Starshollow to correct me, but I think you've got hold of the wrong end of the stick there. As far as I'm aware, the reform you're referring to was that the private insurance companies had to offer a contract equivalent to the public insurance companies. This offered effectively the same cover as the GKK for a cost of up to the maximum that the GKK charged, ie ~500+€, however they are not allowed to reject anybody because of existing health conditions. I can't remember offhand whether this only applies to existing cutomers of the PKK or if anybody can apply.

RMA, you are right on target here...

This is, how the reform-law with the lovely name GKV-WSG (if someone wants to Google details) actually works:

if you are without health insurance now and before you lost your insurance you were a member of the public health insurance, then the public health insurance has to take you back. If however you were a member of a private health insurance in the past, then you have to turn towards the private health insurance(s) to take you back. In a first step since June last year the private health insurances had to take former members back in the same contract/tarrif the former members had with them before they lost them. Starting Jan. 2009 they have to offer the basic tarif which mirrors the public health insurance coverage where they can not deny someone's entry based on pre-existing conditions but where they can ( and you bet they will) charge up to 500.- EUR/month. There is supposed to be a way to half these insurance costs if you can show proof that you can not afford it. How this is going to work, I don't know

The public insurances are currently sueing against this law at the German supreme court and I have a feeling that parts of the law will be overturned by the supreme court, therefore I would not bet high amounts of money if and when this new basic tariffs will really become reality.

The funny thing (well. funny is maybe not the right expression here, come to think of it) is that there are so many Germans ( 200-400 thousand is the range of estimates) without health insurance because they could not get back into their old insurances (or the step back was inattractive because the old contracts where to expensive still) and will probably not even take on the basic tarif because they can not afford it and at the same time there are these international health insurances also available to them where they could at least get for reasonable amount of money coverage for major treatments/illness as in- and out-patient but nobody tells them. I am trying currently to get some media interested in this alternative solution as I fear that even after Jan. 1st 2009 many people will be without health insurance and I think it must be a nightmare not to know what to do when you get seriously ill...

Cheerio

@Starshollow, funny thing, you've mentioned these international insurance schemes a few times in different posts and somehow I never made the connection that they could be interesting for me. I'm at present paying 560+€ / month for my health insurance (late entry in 1990) and that's probably more than my German pension is going to be when I hit 65 in a couple of years. I was seriously thinking of moving back to the UK on paper to solve the problem (only possible once I stop working since being non-resident and working in Salzgitter is probably not too convincing! ). Could you post a quick summary of what's available and whether it's interesting for old-timers like me or is it only interesting for youngsters?

RMA: my first guess out of the hat is that the international insurances will not exactly be an ideal solution for you. However I'll be happy to give you some premium prices and info on the coverage so that you can see if this more limited and selective coverage would work for you or not. On top of that, international insurances get more expensive every year that you grow older, therefore it would most like not be a long-term financially stable solution for you. Getting back into the NHS if you can could be a better way until Germany has figured out how to really reform the messed up health insurance system.

Click on the link below to me or send me a PM with your email address and some personal data like date of birth etc. and I'll send you some personalized info...

Cheerio

Absolutely. Thanks for the pointers. I wont be churlish and point out that ... Never Mind.


That is a little unfair. I can see from what is written by the "industry" here is by and large measured and balanced, but I don't see that as the central point. It's my submission that the decision itself requires the customer to know his/her own future - how sick you might get, what's your marital/family status, how long you going to stay in Germany, how long might you live, and so on. As we all know in life things change. I'll wager my own circumstances are not uncommon - I came to Germany single, and planned on staying that way. 2 years later I am married with a child. I came to Germany for 3 years max, still here after 8. If you look at things from the angle of a single, healthy 33 old guy sitting in Munich in 2000, planning on staying in Germany for just a couple of years, no girlfriend/wife/family, I find it hard to criticize the broker who sold me a top of the range PKV policy with DKV which cost 30% (or more) less than the TK deal on offer and , frankly, I think had I spoken to any of the advisers here I would have got the same advice.

CT

you are of course right that based on an assessment 8 years ago when you would have told me that you intend to stay single and only for a a couple of years, I would have recommended to you too to go with a private health insurance. But there would have been a detailed explanation of the pros and cons on the long run so that this would not have hit you as a surprise if and when your life plan changed at a later point of view. I did not want to imply per se that your broker did a bad job in general, it just sound in your own description like a lot of important information had been left out and that you had to discover bit by bit the potential downsides of your decision later - which is after all not a sign for really good advice.

And the line you quote above was just mirroring the impression you gave me (and others, from what I heard) that you now believe that all brokers and advisors are scum in general and since I try hard every day to cater to the best interest of my clients, this makes me sad (and mad about all those salespeople-calling-themselves-advisor out there who are of course causing enough reason for many people to believe the same like you) and I wanted to point out that we are not all alike...

Cheerio

Spot on. And as you know, I am not alone.


No, that's far from what I think. I think the system itself is too easily abused and misunderstood. and is way too complex to be understood by an ordinary consumer, and too restrictive to cater for many real life, i.e. changing, situations. Therefore, for what I understand, the 2007 reforms making it harder for newcomers to Germany to enter the private system is probably a good thing. And though I can understand why they make it hard to get out, there should be some kind of safety net.

I hold brokers in no lesser regard than any other profession. And I know doctors, medical professionals, who live with their heads in the sand about the system's limitations and blindly tell people that "private is better", without any thought that there might be caveats.

That will be my last word on this in this thread, so I want to Thanks to Starshollow and the others who replied. The problem I started this with remains, my broker (who seems like a decent bloke) is currently looking into it.

CT

seems that I misunderstood you then, CT. my mistake.

Wish you best of luck with finding a solution for the problem which triggered this thread and if something good comes out, maybe you report back to the others here if it could help others in similar situations?

Cheerio