Children of civil servants who are studying are in good hands with private health insurance, but when the family supplement is removed, it becomes expensive. The increase of the private health insurance must be applied for in time, otherwise the insurer can demand risk surcharges or the customer even ends up in the basic tariff.
Students become subject to compulsory insurance in the GKV at the beginning of their studies. But they can object to this and take out private insurance. As a rule, the parents of civil servants then have an 80 percent benefit entitlement for them, and the supplementary 20 percent insurance cover is correspondingly inexpensive.
The official receives the allowance for his studying child as long as the child is eligible for the family allowance. If the family supplement for the child is abolished, the child will have to be insured at 100 per cent in future – so the contributions will increase about fivefold.
At the same time, the child benefit for the child is also omitted – all in all, the civil servant may face an additional monthly burden of a good 400 to 500 euros. The family allowance ceases, for example, when training ends at the end of the calendar year, on the 25th birthday (extended by the period of military/civilian service, if applicable), when certain income limits are exceeded, or on marriage.
Insurance in the GKV is then not always possible because the obligation to insure was objected to at the beginning of the studies. If the official does not notice the change in time, the family allowance and the allowance are cancelled retroactively. According to § 199 para. 2 VVG, however, the insurer is only obliged to adjust the insurance cover to the change in the entitlement to aid – or in this case its discontinuation – without a risk assessment and without waiting periods if this application is made at the latest six months after the change has occurred – and this does not mean only after becoming aware of the change.
In many cases, the official only learns about the loss of the child’s allowance after submitting invoices with the allowance application asking for exactly these changes. If the application is filed pursuant to sec. 199 para. 2 VVG too late, the insurer can demand risk surcharges and benefit exclusions for pre-existing conditions or even refuse the increased insurance cover altogether – in the worst case, the only option left is the basic tariff with limited benefits at the maximum premium of the GKV.
If, for example, the broker has not scheduled the child’s 25th birthday in March, but has postponed the review of coverage to an annual meeting in November, he exposes himself to liability for additional premiums over what would have been required if the application had been made in a timely manner. Customers with a strongly increased risk in private health insurance are often pushed into the basic tariff at the first opportunity, because expensive illnesses are compensated here across all private health insurance companies and no longer increase the premiums in the original tariff.
Brokers and insurers in liability
The following example shows which consulting and liability traps lurk in such constellations: The older of a civil servant’s two children, aged 24, took up dependent employment in the year after exmatriculation – this meant that he was compulsorily insured in the GKV and the family allowance ceased to apply immediately.
He told his broker so that the 20 percent assistance supplemental insurance could be terminated at the same time. The broker immediately canceled the insurance for the child. Eight months later, the civil servant submitted another application for allowance – and was surprised to learn that for the last eight months his own allowance assessment rate was no longer 70 percent, as it had been for two children originally eligible for the family allowance, but only 50 percent.
When the insurance company then applied for an increase in insurance coverage from 30 to 50 percent, it demanded a risk assessment because the time limit of § 199 (2) VVG had been exceeded. The civil servant now had to agree to a risk surcharge for pre-existing conditions of 200 per cent for the additional 20 per cent – as a result, the premium reached almost double the amount charged if the deadline had been met.
The broker was now faced with claims for damages. It is part of the basic knowledge of a PKV broker to know the main features of the law on subsidies, to draw attention to known regulations and to think through necessary measures in all their consequences. However, the insurer also has a duty to advise pursuant to § 6 (4) VVG “insofar as the insurer can identify a reason for inquiring about and advising the policyholder.”
However, it would certainly have been recognisable here that the civil servant’s insurance cover of 30 per cent was presumably no longer sufficient if only one child was still insured in the assistance tariffs. There should then have been an inquiry – and the six-month period of section 199(1). 2 VVG would then still have had to be complied with. According to § 6 paragraph 5 VVG, the insurer is therefore also liable for damages.
However, if the broker had switched the children to another insurer earlier, the broker would not be able to know about the officer’s insurance and thus would have no reason to inquire. Anyone who promises his client “ongoing advice, contract management with support” after the brokerage must implement “risk investigation and property inspection” on a close-meshed basis – annually is not enough.
Often such activities are not even covered by the VSH conditions. If necessary, a “war chest” for one’s own defense or a coverage action is required. Very few insurers or dedicated brokers offer their customers “leaflets on obligations”, from which notification obligations, but also limited application rights can be read.
Finally, the broker can also be held liable if the private health insurance tariff does not provide for continuation as a supplementary insurance with the same benefits in the event of compulsory statutory health insurance – a tariff change claim to a supplementary insurance does not exist according to § 204 VVG for lack of similarity. In case of doubt, the broker has the burden of proof that his client has understood the deficits in the terms and conditions. Whether the amount of the statutory VSH minimum cover will still be sufficient in the event of a claim?
by Dr. Johannes Fiala and Dipl.-Ing. Peter A. Schramm
from www.performance-online.de (published in Performance, issue 11/2010, page 5)
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PhD, 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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