– Why private health insurance (PKV) differently, and often less, than the health insurance (GKV) –

The Federal Court of Justice ruled in its judgment of 11.03.2015 (Case No. IV ZR 54/14): “If an insured person pursues his professional activity at his previous workplace to a limited extent within the framework of a reintegration measure pursuant to Section 74 SGB V, the entitlement to daily sickness benefits shall also lapse if he does not receive a salary from the employer during this measure, but only sickness benefits.”

In retrospect, the daily sickness allowance (KTG) turned out to be a disappointment – the broker had neither provided information nor made any provisions. The case should have been brought against the adviser or intermediary, rather than against the insurer, which makes no sense.

TINA – There Is No Alternative

A common error in thinking is to present a solution as supposedly having no alternative, rather than opening up the discussion. This is common with some politicians, but also when intermediaries only have a specific contract in mind in order to receive a success fee. However, an alternative is almost always to take out insurance in both the GKV and the PKV at the same time – this is not forbidden, but rather a solution that minimises intermediary liability.

Daily sickness benefit does not protect against loss of earnings

PKV pays differently and often less than GKV, where sickness benefits would be paid for reintegration, unlike in PKV according to “model conditions” in PKV (MB/KT).

For the discontinuation of the KT of the PKV, it is sufficient that the doctor certifies the possibility of reintegration, because this alone already establishes that the policyholder (VN) is no longer completely incapable of work. This is also the case if the latter then refuses reintegration. Possibly, and depending on the conditions, there would be the alternative of a “work attempt” instead of reintegration.

Different benefits for reintegration depending on insurance company

Some private health insurers also provide benefits for reintegration, to a greater or lesser extent.

With insurers without such condition extensions one can count partly on goodwill. However, the insured person should only mention this in advance, because anyone who says, for example, that the doctor has already approved reintegration, is at the same time saying that there is no longer a complete inability to work.

Reintegration as a liability case for doctor and employer?

In each individual case, it must be considered in advance which behaviour is sensible and avoids self-harm. The employer’s duty of care implies a considerable obligation to provide advice in the case of reintegration – this also applies to doctors who may consider reintegration to be a good idea for people with private health insurance. If the doctor has already certified the possibility of reintegration and the insurer finds out about it, it is often already too late.

The waiting period until the first benefit period in the event of an illness can also lead to a loss of income: In many general insurance conditions (AVB), this period does not have to be completed again if a new incapacity for work (AU) soon follows for the same reason. However, this would always have to be checked in advance as well, because it may be regulated differently. It would be really bad luck if the reintegration fails and the VR then only pays after another 26 weeks, whereas the employer pays nothing at all for this time. At the latest then the insured asks himself, why he was not informed about it by the mediator, physician and employer – or whether it was only his problem not to inform himself about it in detail?

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