– Why the complete departure from private health insurance is questionable –
(Continued and last part from issue 5517/20 November 2015)
Option: partial maintenance of PKV
If one considers only the premiums of private health insurance and statutory health insurance, savings of up to more than a quarter of a million euros are possible, based on the remaining lifetime. But the design does not have to end there, because there is still the option to remain insured in the private health insurance, possibly combined with a change of insurer. Be it by taking out supplementary insurance policies to the statutory health insurance or by strategically retaining only individual tariff components of the former comprehensive private health insurance. No one can be forced to cancel their PKV because of an insurance in the GKV. It is also possible, for example, to maintain only the outpatient tariff, possibly now with a higher deductible, or to switch to 80% reimbursement if the other tariffs are discontinued. This may require a change of tariff from a compact to a building block tariff.
GKV change via family insurance
Prerequisite for the possibility to get into the GKV family insurance, in order to be co-insured there free of charge with the spouse, is either that one has only a mini-job with a gross income of currently up to 450 euros, or only up to 390 euros – for example as a surplus from rental or capital income or a pension of the DRV. For the most part, this can still be arranged, even if the path to it may initially seem almost impossible. If there is a manageable time gap between employment and receipt of the old-age pension, this will often be just as possible as by reducing an already current full pension to, for example, a one-third pension.
Family insurance can be a first step back into the GKV. If a higher pension or other earned income is received later, the family insurance ends again, but not the statutory health insurance, because the law wants to prevent non-insurance. If the person leaving the family insurance does not prove that he or she has private health insurance – which nobody can force him or her to do – then the GKV will continue compulsorily, albeit with a more expensive assessment of contributions for voluntarily insured persons. Then the further way would still be to be optimized, so around still into the more favorable obligation insurance to come.
In the GKV because of severe disability?
By law, severely disabled persons have three months to apply for admission to the GKV. This deadline is often overlooked. In addition, it requires the detailed study of up to more than 100 GKV statutes in order to know the individual regulations that permit admission to the GKV – or not, for example, if the frequent age limit of 45 years is exceeded. It might be easier to sign up with an artist agency as an extra for theater or television; or offer piano or singing lessons.
PKV change abroad …
For more than 100 Euro per month you can get a so-called expatriate-PKV from foreign private health insurances. Recently also without starting a world trip. With a new foreign PKV, but also suitable in terms of content, the previous domestic PKV insurance can first be terminated. This is because terminating it is ineffective if no suitable new KV insurance cover is proven. Even such PKV from abroad would then be at best a first step of several to permanently reshape the circumstances.
Some PKV does not recognize this as a follow-up insurance, however, because these tariffs from abroad do not meet the requirements of a statutory compulsory insurance, and are therefore void. However, it overlooks the fact that it is sufficient if a comparable entitlement is thus given, which then prevents an insurance obligation from arising in the first place.
… or to a solidarity community or pension foundation
It would also be conceivable that an employer, for example also a so-called entrepreneurial company (UG haftungsbeschränkt), could grant a legal claim to pay for all use of doctors and hospitals, remedies and aids, etc., irrespective of the fact that an insured event – i.e. illness – exists. This means that it is not an insurance company under BaFin supervision, i.e. it is not subject to supervision.
An offer via a self-help association or a pension foundation is also possible. Today, in most cases, no legal entitlement triggering the supervisory obligation is granted for payment only for life risks incurred by corresponding provident funds, but instead a PKV reinsurance policy with the necessary minimum benefits is maintained for this purpose. However, this reinsurance is no longer legally required in the case of a benefit commitment given with a legal entitlement irrespective of illness.
This commitment may only not be limited to life risks, i.e. it must always be paid if you would like to see a doctor for whatever reason or if you want to go to hospital.
Also, a Chinese-style flat-rate premium to the doctor would not be insurance, so if, for example, you pay the doctor with monthly premiums as long as you are healthy – gladly at other times.
Instead of insurance, this is then usually called “life design”. The Federal Financial Supervisory Authority (BaFin) had already let it be heard once that a company which pays a monthly lump sum if one would like to speak to a lawyer – and also does not stop payment if something like a legal protection insurance case were to occur – is not operating an insurance business, but is offering life insurance.
Of course, an actuary can calculate this from the premium and build in proven tools into the product design to keep benefits from getting out of hand. Exclusions, e.g. for cures, dietary supplements, drugs, fertility treatment or illnesses existing at the start of the insurance, even perhaps only for a limited period, are still possible, as are deductibles and limits, exemption from benefits in the event of excess, and even an ordinary right of termination or an extraordinary right in the case of persons who take unreasonable advantage of the offer or do not pay their premium is permitted, as is the fact that at least some kind of plausible explanation is given as to why one has visited the doctor.
In terms of calculation, this does not differ too much from a normal PKV if the product is suitably designed. After all, who goes to the doctor if they don’t have to, and which PKV can check whether the patient was really ill if the doctor notes “suspicion of” as the reason? Also, the innkeeper will not calculate a different price for brunch if everyone is allowed to eat as much as they want, or only as long as they are hungry.
In this way, at least with a genuine legal entitlement – via solidarity-based organisations of one’s own installed in the company, commercially or by foundations and associations – “comparable benefit entitlements” to normal health insurance can then also be organised entirely without an additional minimum reinsurance as an alternative to PKV and GKV, without BaFin supervision and expensive insurance regulation. Of course, actuarially determined capital requirements must be imposed on them if there is not to be a risk that higher invoices will soon lead to insolvency, insofar as this is not covered by reinsurance.
by Dr. Johannes Fiala and Dipl.-Math. Peter A. Schramm
Published in “Der Koment, Fachzeitung für Schausteller und Marktkaufleute” 30.11.2015 (Issue 5518, Page 3)
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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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