The benefits in private health insurance are fixed by contract, but they are not irrevocably fixed, the benefits can also be reduced. Anyone who claims otherwise as an intermediary is liable.
An the face of ever new legally imposed benefit restrictions in statutory health insurance, one advantage of private health insurance is praised: The benefits are contractually fixed here. The fact that this is not always an advantage has already been felt by many when their private health insurance did not reimburse an aid or a certain treatment because these were not included in the contractually stipulated conditions.
This may be despite the fact that the legislator had long since included them in the SHI benefits catalogue. This can only mean that the contractually agreed benefits may not be unilaterally reduced by the insurer.
To compensate for this, however, there is always the possibility of possibly high premium adjustments – in which case the policyholder is free to switch to a slimmed-down and therefore more affordable tariff.
If the policyholder remains with the same insurer, he also keeps the age reserves when changing tariffs.
If, on the other hand, it is contractually stipulated that certain benefits may be reduced, the insurer may also unilaterally make such interventions in the insurance conditions. Lawsuits against the increase of deductibles show that the advice given is not always correct. This is, however, stipulated clearly enough in the premium adjustment clause (§ 8b of the model terms and conditions), and also already in § 12b para. 2 VAG and § 203 para. 2 VVG – always subject to trustee consent.
§ Section 18 of the Model Conditions states:
„In the event of a change in the circumstances of the health care system that is not to be regarded as merely temporary, the General Conditions of Insurance and the tariff provisions may be adjusted to the changed circumstances if the changes appear necessary to adequately safeguard the interests of the policyholders and an independent trustee has reviewed the prerequisites for the changes and confirmed their appropriateness.“
And this gives the insurer the ability to change contractual provisions, including limiting benefits. Nothing else says the law: § 203 para. 3 VVG. Accordingly, the insurer can then adapt not only its general terms and conditions of insurance, but also the tariff provisions.
If the benefits paid increase sharply, this represents a so-called change in the circumstances of the health care system. The PKV insurer then has two options:
He can adjust the premium or change the insurance conditions by reducing the benefits. He needs the approval of an independent trustee for both.
The benefits in private health insurance are only contractually stipulated and can only be changed if the contractual prerequisite for this exists. But they can be changed – they are not irrevocably fixed. An intermediary who tells the customer that the PKV cannot restrict its benefits because they are contractually fixed is putting himself at risk of liability.
However, the insurer often owes the agent recourse if the sales or training manager had grossly misrepresented the PKV tariffs in this respect.
Only the basic tariff and the compulsory long-term care insurance are bound by the statutory benefit provisions. Therefore, their conditions follow the changes made by legislation – the basic tariff will therefore always replicate all the legally prescribed benefit restrictions of the GKV, but also its benefit improvements.
by Dr. Johannes Fiala and Dipl.-Math. Peter A. Schramm
by courtesy of
www.performance-online.de (published in Performance 1-2/2011, page 38)
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About the author
Dr. Johannes FialaPhD, MBA, MM
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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