Is there a threat of deterioration in private supplementary nursing care insurance?

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 deterioration in 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.

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 usually receive several hundred euros less per month for the same impairment (previously in care levels 1 to 3), both for outpatient care and when moving to a nursing home from 2017. The majority of those who will need nursing care in the future and who are not dementia patients will receive far fewer benefits than they would have been entitled to in the past, despite the same amount of nursing care to be paid.

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.

“In dealing with the elderly in need of care, Gröhe has credible Christian and social commitment, which he can now claim for his party. That is why nothing must be allowed to go wrong with the nursing care reform in the year of the federal elections. The changeover has been prepared with the appropriate general staff. In the coming months, no one should be able to say that he has less than before, no one should be able to accuse him of saving at the expense of the elderly in need of care. On the contrary: the motto is: “More for everyone”, wrote the FAZ on 29 December 2016.


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 political lies for their own benefit – at least the really bad 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.

For example, those who have taken out daily nursing allowance insurance (PTV) in order to be properly cared for for as long as they are still in good health, and not to relieve the state when they forget everything right away anyway, now receive fewer benefits in the statutory nursing care insurance. With dementia, he would be classified as having a higher degree of dementia than without dementia, with the same physical need for care (in minutes). 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, some of them small (up to around 5%), which could only be achieved by reducing the benefit commitment for nursing care cases without dementia.


No protection of the interests of all insured persons


The German Association of Acute Care Professionals (DAV) believes that “if necessary, a worse position of individual insured persons should also be accepted”. Furthermore, the DAV believes that “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 with increasing need for long-term care. It would therefore be incompatible with the interests of the insured if, when converting to degrees of long-term care, lower daily allowances were granted for higher degrees of long-term care. The daily care allowance will therefore have to rise as the need for care increases until the advance payment in care level V (100%)” But this is a false conclusion.


Failure 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 scale in the daily nursing allowance rates is then no longer justified, as 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 rates for daily nursing allowance and the nursing allowance are aimed precisely at filling this gap (this is how they were advertised), it is by no means appropriate, as the DAV assumes, to pay more at a higher level, just as it has done so far at a higher level. The DAV says that “the need for care rises 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?


Thus, if necessary, any changes in the terms and conditions that have been made – but are inappropriate – do not stand up to judicial review. An additional premium adjustment as a result of average additional benefits due to the changeover to nursing care levels was not even permitted by law in this context. Noticeable premium increases are therefore only permissible if the strict conditions for a premium adjustment were 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 on 09.01.2017)






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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.
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