Care reform

The Association of Private Health Insurance Companies (PKV Association) has made an effort to understand the collective principles and product concept of supplementary nursing care insurance, including the legal basis. But in vain, because the changes to be implemented for 2017 in the insurance conditions of private supplementary nursing care insurance (PPZ) are based on a violation of the law of thought.


Double deteriorations in private supplementary nursing care insurance

In the waters of the private health insurance association, presumably with only half an understanding of the legal basis, an association of actuaries is on the move: because both are counting on the deterioration in statutory long-term care insurance (GPV) to be followed by a parallel deterioration in private supplementary long-term care insurance. Instead of the financing gaps of the CPA being closed by the PPZ as before, they have now become even bigger for all those who still have their senses together.


Second Care Strengthening Act favours dementia patients living at home

From 2017, there will be five levels of care, replacing the previous three levels of care. Only those in need of physical care will then receive lower care benefits, usually amounting to several hundred euros a month, for the same impairment (previously in care level 1 to 3), both for outpatient care and when moving into a nursing home from 2017. The majority of those who will need care in the future but are not demented will receive far fewer benefits than they would have been entitled to in the past, despite having to pay for the same amount of care.

Only if a level of nursing care has already been applied for or allocated by the end of 2016 will it be protected – but not as soon as the level of nursing care changes in future. This initially conceals the deteriorations so that the extent of this flaw in the care reform is not immediately apparent.


Motto until the federal election: More for all!

FAZ wrote on December 29, 2016:


“In dealing with the elderly in need of care, Gröhe has credible Christian as well as social commitment [gezeigt] that he can now claim for his party. That is why nothing must be allowed to go wrong with the care reform in the year of the Bundestag elections. Accordingly, the changeover was prepared with a general staff. No one should be able to say in the coming months that they have less than they did before, no one should be accused of making savings at the expense of the elderly in need of care. On the contrary, the motto is more for everyone.”

But it is a lie!

The additional benefits for the dementia patients will be financed with cuts for most other future care recipients. The statistics on the extent of those affected are available – but they are kept under lock and key by Health Minister Gröhe and the GKV-Spitzenverband. The PKV Association has received them for calculation purposes, which means that extracts of them have already been shown at lectures. However, there is no paper on the matter because of Gröhe’s ban on publishing them – the PKV association simply writes that Gröhe has forbidden him to pass on the figures. This plays into the hands of political opponents who use the lies of politics for their own ends – at least the really badly made ones. With such general staff work Napoleon’s Russian campaign would have ended at the Rhine crossing. In the Ministry of Defense you would now at least know what you have a service pistol for – in the Ministry of Health you are more concerned with health.


2017 one-off rate change in supplementary long-term care insurance

Who for example a care daily allowance insurance (PTV) locked, in order to be maintained as long as he is still in the senses decently, and not in order to relieve the state, if he forgets everything anyway immediately again, which receives now less achievements already in the legal care insurance. With dementia, he would be classified at a higher level than without dementia for the same physical need for care (in minutes). According to the will of the legislator, the PTV calculated according to nursing grades should collectively result in approximately the same scope of benefits as previously calculated according to levels. This is implemented by the private health insurance companies, in that the lower degree (without dementia) receives less, the higher degree (with dementia) however, more daily care allowance than the same person would have received previously according to their level of care.

According to initial information, insurers have already implemented this in some cases and sent customers adjustments, in some cases small amounts (up to around 5 percent), which could only be achieved by reducing the benefit commitment for care cases without dementia.


No protection of the interests of all insured persons

The German Association of Actuaries (DAV) believes that if necessary, a worse position of individual insured persons should also be accepted.

In addition, the DAV:

“When adjusting the benefit levels, it will also have to be taken into account that, according to the legal assessment (and also practical experience), the need for care increases as the need for care increases. It would therefore not be compatible with the interests of the insured persons if lower daily nursing allowances were granted for higher nursing grades when converting to nursing grades. The daily care allowance will therefore have to increase with increasing need for care up to the advance payment in care degree V (100 percent).”

But this is a false conclusion!


False conclusion of the PKV actuaries

This is because up to now, the daily nursing allowance tariffs have provided for an increase in benefits according to levels. In the case of inpatient nursing care, the benefits of compulsory nursing care insurance also increased with the nursing care level, but the financing gap to actual requirements was nevertheless greater at higher levels. For this reason, the rates for daily nursing allowance were also staggered in order to fill this gap in a more demand-oriented manner. Now, however, according to degrees, every in-patient nurse has exactly the same gap in euros (as it were the same calculated own contribution), in all degrees of care. This even increases in the lower levels of care (which is deliberate in order to keep these people in need of care at home). A sliding scale in the daily nursing allowance tariffs is then no longer justified, since it closes the gap in the higher grades far more than before, but in the lower grades it widens the – increased – gap even more.

This also applies analogously to outpatient nursing care, because if compulsory nursing care insurance here now also classifies and provides graduated benefits more fairly (in line with requirements) according to degree, the previous increase in the gap will also be mitigated here as the severity of the need for nursing care increases compared with the previous situation. However, since the daily nursing allowance tariffs as well as Pflege-Bahr are aimed precisely at filling this gap (as they were advertised), it is by no means appropriate, as assumed by the DAV, to pay more at a higher level, as has been the case up to now.

The DAV says that “the need for care increases as the need for care increases”. In the case of a supplementary insurance, however, it is not the overall need for care that is important, but the gap that remains after the change to the compulsory long-term care insurance that is now more in line with the need for care.


Changes in conditions and premium adjustments ineffective?

Any changes in conditions that have been made – but which are unreasonable – will therefore not stand up to judicial review. In this context, an additional premium adjustment as a result of average additional benefits in connection with the changeover to nursing grades was not even permitted by law. Significant premium increases are therefore only permissible if the strict conditions for a premium adjustment are met.

Some private health insurers may risk that the adjustments to premiums and conditions for 2017 will later be declared invalid by the courts.


by Dr. Johannes Fiala and Dipl.-Math. Peter A. Schramm


by courtesy of (published in issue 02/2017, pages 42-45)


Our office in Munich

You will find our office at Fasolt-Strasse 7 in Munich, very close to Schloss Nymphenburg. Our team consists of highly motivated attorneys who are available for all the needs of our clients. In special cases, our law firm cooperates with selected experts to represent your interests in the best possible way.

About the author

Dr. Johannes Fiala Dr. Johannes Fiala

Dr. Johannes Fiala has been working for more than 25 years as a lawyer and attorney with his own law firm in Munich. He is intensively involved in real estate, financial law, tax and insurance law. The numerous stages of his professional career enable him to provide his clients with comprehensive advice and to act as a lawyer in the event of disputes.
»More about Dr. Johannes Fiala

On these pages, Dr. Fiala provides information on current legal and economic topics as well as on current political changes that are of social and/or corporate relevance.

Arrange your personal appointment with us.

Make an appointment / call back service

You are already receiving legal advice and would like a second opinion? In this case please contact Dr. Fiala directly via the following link.

Obtain a second legal opinion

(The first phone call is a free get-to-know-you conversation; without consulting. You will learn what we can do for you & what we need from you in terms of information, documents for a qualified consultation.)