Sick people are excluded

Munich. The basic tariff, which private health insurers are to offer in the future, excludes sick people. The insurance experts PM Dr. Johannes Fiala and Dipl.-Math. Peter A. Schramm from Munich point this out. With the health reform the basis tariff is to take up in the private health insurances to each entitled one – that are voluntarily legally health-insured, uninsured, privately health-insured – independently of the state of health. For pre-existing conditions, neither risk surcharges nor exclusions may be levied. For someone who is already ill, the basic tariff could lead to an unexpected disappointment. He will not receive any benefits at all for his illness, according to the experts. Pre-existing conditions – or their consequences – were not “excluded”, but it was an ongoing insurance case that had already occurred before the start of the insurance. This is the essence of insurance in general – one cannot insure anything that is not uncertain but certain because it has already occurred before the start of the insurance. In general, a spinal disease, for example, is not excluded, but nothing is paid by the insurance company for the current insured event until it ends. The fact that the new health reform does not allow any exclusions is meaningless. 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.” – this is how § 2 of the model conditions for medical expenses and daily hospital allowance insurance clearly states it. In the case of the spinal column patient in the above example, there is a pre-existing condition that is not excluded, but if the patient is treated for it before the insurance begins, this insured event is excluded until the doctor determines that – for the time being – there is no need for further treatment. In the case of the chronically ill, for whom there is often no end to the need for treatment, the situation is even worse, according to the experts. If he changes into the basic tariff of the private health insurance, he is admitted first without risk surcharge and without exclusions. However, he would not receive any benefits for this chronic illness. The government is thus luring people who were previously insured elsewhere and even forcing those who were previously uninsured into a basic tariff, for which they would have to pay premiums but then receive no benefits at all for their existing chronic illnesses. The really sick could therefore still not change.
Expert’s office Peter A. Schramm, graduate mathematician, actuary DAV, expert for actuarial mathematics, publicly appointed and sworn by the IHK Frankfurt am Main for actuarial mathematics in private health insurance,, www.pkvgutachter. de Fiala Law Office, RA & Mediator, MBA Financial Services (Univ.Wales), MM (Univ.), Bankkaufmann (IHK), Certified Financial and Investment Advisor (A.F.A.),,
(ku-newsletter from 05.02.2007, 9)

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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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