Letter to the editor from 13.8.2007
Clarified questions to the standard tariff, already long before the resolution of the WSG was pointed out by Fiala/Schramm that in the basis tariff (and naturally likewise in the standard tariff) current insurance cases are excluded from the obligation to perform. So for example published to 05.02.2007 in the contribution ?ill ones are excluded? in ?hospital market? of 05.02.2007 ( – see pdf file – ) there already the ?error? of the Federal Ministry of Health is cleared up in detail: ?but for the current insurance case up to its termination by the insurance nothing is carried out. The fact that with the new health reform no exclusions are permitted, goes to that extent into the void. There was no need for express exclusions where there was already no obligation to pay benefits by law. According to the Insurance Contract Act (VVG) and the Insurance Supervision Act (VAG), the core of every private insurance contract is that it must cover uncertain future losses: Thus, if private health insurers were forced to co-insure certain known claims, this would be a special sacrifice that is obviously no longer constitutionally proportionate. In health insurance, the insured event – according to § 1 of the model conditions of the Association of Private Health Insurers – is the medically necessary treatment. It therefore begins conditionally with the medical treatment and ends only when there is no longer a need for treatment. It is therefore a so-called “extended” insured event. If there is a need for treatment until the end of life, then the insured event is also extended until then. In the extreme case, there is no obligation to pay benefits for the insured event that already occurred before the start of the insurance – even if the previous illness was not excluded or – after the new health reform – may not be excluded at all. “No benefits will be paid for insured events that occurred before the start of the insurance cover.” – so § 2 of the model terms and conditions for medical expenses and daily hospital allowance insurance makes it unambiguously clear.” It can therefore hardly be assumed that the legislator simply “got it wrong” by “confusing” pre-existing conditions and current insured events – as assumed by the PKV Association. Rather, the legislator is likely to have deliberately left out current insured events – the article also points out why: namely because otherwise there would have been another heavyweight reason for the unconstitutionality of the law. Insurers would do well not to pay for claims in force at the start of the standard tariff. After all, this would either burden the remaining customers or the shareholders if the premium adjustments required as a result were not allowed to be implemented for legal reasons (the company’s own fault). In any case, however, there is otherwise a possible accusation of breach of trust – which has already brought investigations by the public prosecutor’s office and penalties for other former insurance directors.
Peter A. Schramm
(versicherungsjournal.de letter to the editor of 13.8.2007)
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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.
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