Comprehensive health insurance policy
Provisit Student / Science
This fact sheet provides you with an overview of your coverage under the comprehensive health insurance policy Provisit Student. Please note that this information is not exhaustive. You will receive details from us in the insurance conditions and other comprehensive health insurance policy documents. These consist of the conditions for our insurance tariff DR-WALTER come-in (part II), the General Insurance Conditions AVB/Impats (part I), customer information and the insurance policy. For comprehensive information, please read all the documents.
What type of insurance is this?
This policy is a comprehensive health insurance policy that replaces the coverage provided under compulsory German health insurance (GKV). It protects you against financial risks arising from the costs of, for example, outpatient or inpatient medical treatment by doctors.
What is insured?
The comprehensive health insurance policy provides coverage for illnesses, accidents and other events specified in the contract. This includes, for example:
- 100% of the costs of outpatient and inpatient medical treatment*
- 100% of the costs of targeted preventive medical examinations*
- 100% of the cost of medicines*
* applies for primary care physicians. In case of a direct visit to a specialist or prescription directly by a specialist: 75%
- Benefits for dental treatment, dental prophylaxis, dentures and orthodontics
- 75% of psychotherapeutic treatment costs
- 100% of the costs of approved remedies
- 100% of the costs of medical aids
- 100% of midwife and maternity services costs
- 100% of follow-up treatment costs
- 100% of home nursing care costs
- Reimbursement for the costs of return transport and transport of mortal remains
- Daily hospital allowance of € 30, from the 15th day in hospital
- Convalescence allowance of € 1,500
- 100% of the costs of inpatient hospice services
What is not insured?
Not covered, for example, are:
- Illnesses and accidents caused intentionally by the insured person.
Are there any restrictions on cover?
For example, coverage is limited in the following cases:
Only applies to the Student tariff:
- The tariff provides for a deductible of € 300 per insurance year. You must cover any incurred costs up to this amount.
The following applies to the Student and Science Tariff:
- In hospitals, you use accommodation and meals in a single room (optional benefits) although only a multi-bed room (standard benefits) is insured. You must cover any additional incurred costs.
- For certain types of benefits, maximum percentage limits or reimbursement rates below 100% of the invoice amount have been agreed (e.g., psychotherapy). You will have to pay the difference yourself.
- For certain types of benefits, maximum percentage limits or reimbursement rates of the invoice amount have been agreed (e.g., dentures). You will have to pay the difference yourself.
- In the case of childbirth, psychotherapy, dentures and orthodontics, a waiting period of 8 months from the start of insurance applies.
- At the start of outpatient medical treatment, a primary care physician must first be consulted for full reimbursement. If a specialist is consulted directly, the reimbursement is reduced to 75% of the invoice amount.
Where am I covered?
- The comprehensive health insurance policy provides you with insurance coverage in Europe. In the event of a temporary stay in non-European countries, insurance coverage is provided for one month without a special agreement.
What are my obligations?
For example, the following obligations apply:
- A medical examination is carried out before the contract is concluded. Therefore, you must truthfully provide all the information requested by the insurer
- In order for benefits to be paid, you must provide the required proof.
- You are obliged to pay the premiums in full and on time. In case of delay, you may be charged additional costs.
- You are obliged to notify us immediately of the conversion of your residence permit for Germany into an unlimited one.
- At our request, you are obliged to provide any information on the occurrence of an insured event or if we have a liability to pay benefits and its scope.
When and how do I pay?
- The premium will be debited from your account on a monthly basis or as a one-time payment according to the agreed payment method when due.
- If the fee is monthly, it is due on the first day of each month.
When does the cover start and end?
- The insurance begins on the date specified in the insurance policy.
- The contract is concluded for an indefinite period, but for a maximum of five years.
- The insurance coverage ends – also for pending claims – with the termination of the insurance contract.
How do I cancel the contract?
- You can terminate the contract if the obligation to insure in the comprehensive health insurance ends, e.g., due to the entry of the obligation to insure in the German compulsory health insurance system, or upon termination of your stay in Germany.
- If the obligation to insure continues, your termination will not take effect until you prove to us within the notice period that you are covered by a new insurer without interruption.
Provisit Student / Provisit Science
General Customer Information
We, DR-WALTER GmbH, want to provide you as our customer with the following comprehensive information about the involved insurance companies and the underlying insurance policies. These insurance policies are offered exclusively through DR-WALTER GmbH and its distribution partners.
1. Type of insurance contracts
The following applies to health insurance:
The policies Provisit Student and Provisit Science are comprehensive health insurance policies in accordance with section 146 Insurance Supervision Act (VAG) in combination with section 195 (3) German Insurance Contract Act (VVG).
2. Identity of the companies involved
To offer you these insurance policies, DR-WALTER GmbH has teamed up with a renowned insurance company.
Insurance coverage for health insurance is provided by:
Barmenia Krankenversicherung AG
Barmenia Allee 1
42119 Wuppertal, Germany
District Court Wuppertal HRB 28475
The contract and service management is carried out by:
53819 Neunkirchen-Seelscheid, Germany
District Court Siegburg HRB 4701
DR-WALTER GmbH acts as an insurance agent for one or multiple clients in accordance with section 34d (1) Industrial Code. The competent authority is IHK Bonn/Rhein-Sieg, Bonner Talweg 17, 53113 Bonn, T +49 228 2284 -0, F +49 228 2284 -170, email@example.com, www.ihk-bonn.de.
DR-WALTER GmbH is registered in the register of insurance intermediaries under the number D-QAMW-L7NVQ-57. This entry can be reviewed online at www.vermittlerregister.info or in the Register of Insurance Brokers (Versicherungsvermittlerregister) at Deutscher Industrie- und Handelskammertag (DIHK) e. V., Breite Straße 29, 10178 Berlin, T +49 (0) 180 600 585-0, (landline price €0.20 / call; mobile phone prices maximum €0.60 / call). DR-WALTER GmbH has a direct interest of 100% in the voting rights of DR-WALTER Versicherungsmakler GmbH. No insurance company or parent company of an insurance company has a direct or indirect interest of more than 10% in voting rights or capital of DR-WALTER GmbH.
3. Authorized representatives of the companies involved
The legal representative of Barmenia Krankenversicherung AG is the Management Board as follows: Dr. Andreas Eurich (CEO), Frank Lamsfuß, Ulrich Lamy, Carola Schroeder; Chairman of the Board: Dr. h. c. Josef Beutelmann.
Legal representatives of DR-WALTER GmbH are the managing directors.
4. Main business activity of the insurers
Barmenia Krankenversicherung AG offers all types of health and long-term care insurance.
Legal and financial supervision is carried out by the Bundesanstalt für Finanzdienstleistungsaufsicht (Federal Financial Supervisory Authority), Graurheindorfer Str. 108, 53117 Bonn, Germany.
5. Guarantee and security fund
The following applies to Barmenia Krankenversicherung AG:
Medicator AG, Bayenthalgürtel 26, 50968 Cologne, Germany, in agreement with the Federal Financial Supervisory Authority, protects policyholders from the consequences of the insolvency of a health insurance company.
6. Key features of the benefits
The General and Special Conditions of Insurance (AVB) describe type and scope of the insurance benefits and contain all other regulations.
The entire content is derived from the following documents:
- General Insurance Conditions for Temporary Stays in Germany (AVB/Impats), of Barmenia Krankenversicherung AG,
- Tariff Conditions DR-WALTER come-in, of Barmenia Krankenversicherung AG,
- For further information, please refer to the general and additional customer information and the respective fact sheet,
- The insurance policy documents the concluded insurance contract.
The data to be provided by you and any documents to be submitted serve in particular to specify the desired insurance coverage.
Collateral agreements (e.g., verbal commitments made by your insurance agent) are only binding if they are confirmed in writing by DR-WALTER GmbH or the insurance company involved.
7. Total price of insurance
The premiums are monthly premiums. These are due in advance at the beginning of each insured calendar month. The total premium consists of the individual premiums of the selected insurance policies. Based on your selection, the total premium will be shown on our website, as well as in the consultation protocol and your insurance certificate.
The premiums for health and long-term care insurance are free of tax in accordance with section 4 no. 5 Insurance Tax Act (VersStg).
8. Taxes, fees and expenses
The following applies to health and long-term care insurance:
In the event that you fall behind with your payments, the dunning costs specified in the insurance conditions as well as late payment fines, may be incurred. There are no other taxes, fees or charges.
9. Details of payment of premiums
The premium is a monthly premium and is due in advance at the beginning of each insured calendar month.
10. Validity of the information provided
The information provided is generally not limited in time.
11. Conclusion of the contract
After submitting your necessary data, you will receive a binding offer from DR-WALTER GmbH. The insurance contract is concluded at the requested start of insurance if you accept this offer in due time. The earliest possible start of insurance is the date of entry into Germany by the person to be insured. For persons who are not insurable, no insurance contract comes into effect even in case of payment or receipt of the premium. If the premium is paid for an uninsurable person nonetheless, the sender is entitled to the premium (less the expenses of DR-WALTER GmbH).
12. Information on the right of revocation in accordance with section 8 (2) no. 2 German Insurance Contract Act (VVG)
Right of revocation
You can revoke your contractual declaration in writing (e.g., letter, fax, email) without giving reasons within two weeks after conclusion of the contract. The period shall commence after you have received the insurance policy, the policy provisions including the general insurance conditions, the further information in accordance with section 7 (1) and (2) of the German Insurance Contract Act (VVG) in combination with section 1 to 4 of the VVG Decree on the Duty to Inform (VVG InfoV) and this instruction, each in writing. Timely sending of the revocation statement is sufficient for complying with the revocation period.
Please send your revocation to
Barmenia Krankenversicherung AG
c/o DR-WALTER GmbH
T +49 (0) 22 47 91 94 -0
F +49 (0) 22 47 91 94 – 40
Consequences of revocation
In case of an effective revocation, you are no longer bound to the contract. If insurance cover was provided prior to the end of the revocation period, the insurer is entitled to the part of the premium attributable to the time until the revocation is received. Any premiums paid in addition to that shall be refunded by the insurer.
You can use the following text sample for your revocation:
I hereby revoke the contract I concluded.
Insurance policy number:
Name of the policyholder:
Address of the policyholder:
Signature of the policyholder (in case of written notification):
Your right of revocation is excluded if the contract has been completely fulfilled by both parties at your express request before you have exercised your right of revocation.
End of information on the right of revocation
13. Contract period
The following applies to health insurance:
With regard to health insurance of a person with a temporary (i.e., limited) residence permit, the insurance contract ends on the end date specified by the policyholder, but no later than after five years. The minimum contract period is two months. After five years, or if the duration of the residence permit is no longer limited, the policyholder has the right to continue his/her insurance coverage in the tariff Eins A Prima 1 of Barmenia Krankenversicherung AG. This tariff can be continued without another medical examination.
14. Information on the termination of the contract
The following applies to health insurance:
The policyholder may terminate the insurance contract without notice at the end of every month. The termination shall take effect on the first of the following month. If the insurance contract serves the fulfillment of the obligation to insure, the termination requires that a new contract be concluded for the insured person with another insurer that meets the requirements for the obligation to insure.
15. Applicable law and place of jurisdiction
The contract is subject to German law and German jurisdiction. Should it ever be necessary to resolve a dispute in court, you can file suit in the courts with the following local jurisdiction:
- Your place of residence or habitual residence, Wuppertal as the headquarters of Barmenia Krankenversicherung AG against Barmenia Krankenversicherung AG,
- The court of your place of residence or habitual residence shall have jurisdiction over any action brought against you.
- In the event of departure to a foreign country outside the European Union / European Economic Area, the place of jurisdiction shall be Wuppertal for lawsuits against Barmenia Krankenversicherung AG. The same applies if your place of residence or habitual residence is unknown.
Our correspondence with you will be both in English and German.
17. Appeal proceedings
In the event of a disagreement, please contact DR-WALTER GmbH.
Our contact data are:
T +49 (0) 22 47 91 94 -0
F +49 (0) 22 47 91 94 -40
We will try to find a mutually acceptable solution as quickly as possible. If we don’t succeed in this endeavor, you can also contact an extra-judicial arbitrator:
For complaints that affect your health or long-term care insurance, please contact the
Ombudsmann für private Kranken- und Pflegeversicherungen (ombudsman for private health and long-term care insurance)
T +49 (0) 800 2 55 04 44 (free of charge from German telephone networks)
F +49 (0) 30 20 45 89 31
For more information, please go to www.pkv-ombudsmann.de
This ombudsman is both responsible for extra-judicial arbitration in the event of a dispute arising from insurance contracts with consumers and between insurance brokers and policyholders. The policyholder’s right to take legal action shall remain unaffected hereby.
In addition, you can file a complaint with the
Bundesanstalt für Finanzdienstleistungsaufsicht (Federal Financial Supervisory Authority)
Graurheindorfer Straße 108
T +49 (0) 228 41080
F +49 (0) 228 4108 1550
Health Insurance Fact Sheet of the Federal Financial Supervisory Authority
In the press and in public, terms are used in connection with private and compulsory health insurance that require explanation. This fact sheet aims to briefly explain the principles of compulsory and private health insurance.
1. Principles of compulsory health insurance
The German compulsory health insurance system is based on the principle of solidarity. This means that the amount of the premium does not depend primarily on the scope of benefits, which is essentially defined by law, but on the individual fitness of the insured member determined according to certain flat-rate rules. Premiums are regularly assessed as a percentage of income. Furthermore, the insurance premium is charged on a pay-as-you-go basis. This means that all expenses in the calendar year are covered by the premiums received in that year. Apart from a statutory reserve, no other accruals are created. Under certain conditions, spouses and children are also insured free of charge.
2. Principles of private health insurance
In private health insurance, a separate premium needs to be paid for each insured person. The amount of the premium depends on the age and the state of health of the insured person at the time of conclusion of the contract and on the tariff concluded. Risk-adjusted premiums are charged, which are calculated in accordance with actuarial principles.
The higher utilization of health care services with increasing age is taken into account by old age provisions. The calculation assumes that health care costs do not increase and that premiums do not rise solely because the insured person is getting older. This calculation method is referred to as Anwartschaftsdeckungsverfahren (funding procedure for future pension payments) or Kapitaldeckungsverfahren (funding principle). A change of the private health insurance company is usually possible at the end of the insurance year. It should be noted that for the health insurers – with the exception of insurance in the basic tariff – there is no obligation to accept the insured person; in addition, the new insurer will demand another medical examination and the premiums are charged with regard to the age the insured person will then have reached. Part of the calculated old-age provision can be transferred to the new insurer (If you already had private health insurance before 01.01.2009, special regulations apply to you. Please obtain separate information on these regulations, if applicable). The remaining part may be taken into account when calculating the premium of a supplementary insurance policy if such a policy is taken out; otherwise it will remain with the previous group of insured persons. A return to compulsory health insurance is generally ruled out, especially in old age.
Additional customer information on health insurance
Note: This customer information relates to the comprehensive health insurance policies Provisit Student and Provisit Science.
1. Effects of rising health care costs on future premium development
The development of health care costs depends on an extraordinarily large number of factors – making a forecast very difficult. Based on the experience of the past decades, medicine will continue to advance and patients’ demands for medical care will continue to increase.
In diagnostics, for example, computed tomography (CT) and magnetic resonance imaging (MRI) are being used more and more frequently so that targeted therapy can be initiated quickly. The use of expensive high-tech medicine and its further development is just one example of medical progress and the many possibilities that now exist for treating illnesses and thus improving the patients’ quality of life. This, too, means that health care costs will continue to rise – for those with private insurance as well as for those with compulsory insurance, for both the younger and the older generation. The illustration on the back of this customer information gives you an impression of the influence of rising medical costs on the development of health insurance premiums.
2. Options to slow the increase of premiums later in life
The tariffs Provisit Student and Provisit Science can be taken out by persons who enter Germany from abroad and are subject to compulsory health insurance or a comprehensive health insurance policy within the German health insurance system. The insurance period of the two tariffs is limited to a maximum of five years in accordance with section 195 (3). Accordingly, the planned stay in Germany should not exceed five years. As a result, measures to slow the increase of premiums later in life are not included in these tariffs. Should the option be taken, e.g., if it is decided to no longer limit the duration of the residence permit, to change to another unlimited tariff within a comprehensive health insurance policy, the following applies:
In addition to the surcharge in compulsory health insurance, which is accumulated and used from the age of 65 to slow any increases of premiums that then become necessary, provision can be made, for example, by agreeing to a reduction in premiums in the future. From the age of 65, the health insurance premium is reduced by the agreed reduction amount. Furthermore, there are also other ways to make provisions, e.g., with a Finanzierungsrente (particular type of pension).
In accordance with section 204 of the German Insurance Contract Act (VVG), it is possible to switch to other tariffs of the insurer with similar insurance coverage.
Older insured persons who live in Germany also have the option of agreeing to the industry-wide standard tariff or basic tariff. In both cases, access is subject to certain legal requirements, with the premium being limited to the maximum premium within compulsory health insurance. If payment of the premium for the basic tariff results in financial need for assistance within the meaning of the German Social Code (SGB), in particular Book 2 SGB or Book 12 SGB, the respective maximum premium is reduced to half for the duration of the need for assistance. The same applies if there is a need for assistance regardless of the amount of the premium. In these cases, the Federal Employment Agency or cities and municipalities, as the respective responsible institution, may grant a subsidy upon application under the conditions specified in section 152 (4) of the Insurance Supervision Act (VAG).
3. Possibility of changing to compulsory health insurance at an advanced age
A change to compulsory health insurance is usually not possible at an advanced age. It is possible, however, in case the affected person becomes subject to compulsory insurance or entitled to family insurance. However, changing to compulsory health insurance is not possible for persons who have reached the age of 55 and have not been insured in the compulsory health insurance system in the last five years (except for recipients of unemployment benefits (Arbeitslosengeld II) and persons entitled to family insurance).
4. Possibility of changing within private health insurance at an advanced age
A change within private health insurance at an advanced age may result in higher premiums and may be limited to the standard or basic tariff of private health insurance.
5. Development of premiums over the preceding ten years
The following overview of premiums shows how the premiums of the substitutive private insurance tariffs have developed for the named person if these were taken out individually by a person of the same sex 10 years ago (or in the year of the introduction of the tariff) at the age of 35, whereby January 1st is always assumed to be the start of insurance coverage.
Here, the data refer only to rates for substitutive health insurance. The premiums include the surcharge in compulsory health insurance. Possible risk premiums as well as a possible group discount or a discount for Sammelinkasso insurance (particular form of group insurance) are not taken into account. These would develop accordingly.
For tariffs that have not yet been offered for 10 years, the informative value of the premium development is limited (no premium is shown for tariffs that were only introduced after January 1st of the current year). In addition, the following overview of the tariff offered shows the development of a comparable tariff, if such a tariff is available. This tariff is marked with (R) as “reference tariff”. For tariffs that include a daily allowance or a certain reduction of the premium (Beitragsentlastung), an amount of €50 is assumed.
Deviating amounts develop at an equal ratio. With regard to the special conditions for persons in vocational training, the corresponding standard tariff – with the addition (R) – is always used as the reference tariff. This applies equally to insurance tariffs for civil servants, which can only be taken out by children and adolescents. If the standard tariff has not yet existed for 10 years, the associated reference tariff is again indicated.
reference tariff from Barmenia Krankenversicherung AG
|VCH3C(R)||470,17 €||412,06 €||342,78 €||342,78 €||342,78 €||292,03 €||292,03 €||276,84 €||276,84 €||276,84 €|
Additional information on the conditions and premiums of health insurance
The following information provides you with an overview of the underlying insurance conditions for the desired tariffs. The complete contents of the contract are set out in the insurance policy, the customer information and the insurance conditions. Please read the entire terms of the contract carefully.
1. Type of insurance contract offered
Comprehensive health insurance policy
2. Description of the insurance coverage and any excluded risks
Scope of the agreed insurance coverage in the tariffs Provisit Student and Provisit Science:
Compact tariff with benefits for outpatient, inpatient and dental treatment; optionally with a deductible of €300 (Provisit Student) or €0 (Provisit Science) per insurance year. The insurance coverage is based on the following insurance conditions:
- General Insurance Conditions for Temporary Stays in Germany (AVB/Impats),
- Tariff Conditions DR-WALTER come-In.
For details of the insurance coverage, please refer to sections 4 et seqq. “Scope of the liability to pay benefits” of the general insurance conditions and the tariff conditions.
3. Amount of premiums to be paid, their due date, as well as the period for which the premiums are to be paid and the consequences of non-payment or late payment
The total monthly premium results from the selected tariff as well as from the individual access requirements of the insured person. The following table illustrates the possible monthly premiums:
|Provisit Student up to 29 years||€69|
|Provisit Student up to 45 years||€89|
|Provisit Student up to 45 years (without further training)||€109|
|Provisit Student up to 45 years (accompanying spouse / life partners)||€109|
|Provisit Student up to 17 years (accompanying children)||€89|
|Provisit Student up to 59 years||€350|
|Provisit Student up to 60 years||€600|
|Provisit Science up to 29 years||€79|
|Provisit Science up to 59 years||€129|
|Provisit Science up to 59 years (without funding)||€150|
|Provisit Science up to 59 years (accompanying spouse / life partners)||€150|
|Provisit Science up to 17 years (accompanying children)||€99|
|Provisit Science up to 60 years||€620|
The premium of the respective age group is valid until the end of the month in which the maximum age of this age group was reached. After that, the premium of the next age group is to be paid.
Unless another payment method is agreed, the insurance premium is due monthly – on the first of the month. If a direct debit authorization has been given, the premium will be debited from the specified account on the due date in each case. In case the parties agreed to a different payment method (e.g., bank transfer, standing order), the payment must take place in due time before the due date. Failure to pay or late payment of premiums jeopardizes the agreed insurance coverage and, under certain circumstances, the continuation of the contract. For details, please refer to section 8 “Payment of premiums” of the respective general insurance conditions.
There are costs involved in arranging and taking out health insurance. Acquisition costs include all costs directly attributable to the establishment of a contract, i.e., advertising, consulting and brokerage expenses, risk assessment, issuance of the contract, etc. There are also other costs associated with managing the contract. This includes, for example, the costs of implementing changes to contracts or maintaining your personal data (e.g., change of address or change of bank details), as well as for the management and maintenance of contracts, debt collection and compliance with statutory regulations as part of proper accounting practice. Therefore, acquisition and distribution costs and other costs must be covered for the insurance coverage, whereby the following information only refers to the substitutive comprehensive health insurance. Any risk surcharges are not taken into account. The same applies to any group discount or a discount for Sammelinkasso insurance (particular form of group insurance) that would reduce the reported costs.
In the Provisit Student and Provisit Science tariffs, there is a cost of 25% of the monthly premium payable. The costs are already included in the total monthly premium. The costs are always to be paid during the entire term of the contract. In the event of a premium adjustment, the percentage of costs to be paid usually remains the same. Should the payment of premiums not be made as agreed, further expenses will be incurred in addition to those already included in the premiums, which may be invoiced. This relates to costs incurred by the return of direct debits, a reminder fee for expenses incurred in processing reminders and, where applicable, default interest or surcharges for late payment.
The premiums for long-term care insurance and large parts of the premium for comprehensive health insurance are tax deductible. Depending on the individual tax situation, this may result in savings on premiums.
The following percentages of the paid annual premium are tax deductible:
1. In tariffs Provisit Student and Provisit Science (comprehensive health insurance policy)
- 93.16 % of the paid annual premium.
2. In tariff Provisit Pflege (private compulsory long-term care insurance)
- 100 % of the paid annual premium.
Tariff conditions DR-WALTER come-in
Tariff for primary care physician services with benefits for outpatient and inpatient medical treatment, dental treatment and dentures
As of 01 April 2021
As Part II of the General Insurance Conditions for Health Insurance and Daily Hospital Allowance Insurance, the tariff DR-WALTER come-in is only valid in combination with Part I, General Insurance Conditions for Temporary Stays in Germany (AVB/Impats).
Tariff designation in the insurance policy
In the insurance policy, the tariff DR-WALTER come-in is shown with the following tariff designation and benefit levels (= amount of the deductible per insurance year):
Provisit Science in combination with benefit level 1: Deductible = €0
Provisit Student in combination with benefit level 2: Deductible = €300
As of 01 April 2021
The following is an overview of the benefits of the DR-WALTER come-in tariff. The exact range of services and benefits can be found on the following pages.
|primary care physician*||100%|
|targeted preventive examinations (primary care physician)*||100%|
|* In case of a direct visit to a specialist or prescription directly by a specialist||75%|
|services of midwives and male midwives||100%|
|psychotherapeutic treatment, with prior approval by the insurer||75%|
|approved remedies according to German state aid rules||100%|
|medical aids according to clause 1.1 e)||100%|
|home nursing care||100%|
|general hospital services||100%|
|dental treatment, dental prophylaxis
|€500 per insurance year|
|dentures and orthodontics||50%||€500 per insurance year|
|dentures due to an accident||100%||€2.500 within two insurance years|
|Convalescence allowance (according to clause 1.8)||€1.500 per claim|
|inpatient hospice services (according to clause 1.9)||100%|
Eligible for insurance
- are persons traveling to Germany with a residence permit for Germany limited to a maximum of five years
- their accompanying spouses, domestic partners and children, if they also have a temporary residence permit for Germany.
In accordance with the insurance contract, the insurer shall refund the proven expenses in the event of an insured event to the following extent.
1.1 Outpatient medical treatment
a) Outpatient medical treatment by doctors
The DR-WALTER come-in tariff focuses on the so-called primary care physician model for outpatient medical treatment by doctors. This means that for certain benefits, the amount of insurance coverage depends on whether a primary care physician is consulted first for outpatient medical treatment.
As primary care physicians are considered exclusively:
- general practitioners,
- internists without a specialty designation (specialty designations include angiology, endocrinology, gastroenterology, hematology, internal oncology, cardiology, nephrology, pneumology, rheumatology),
- emergency physicians or doctors on call.
In the case of treatment by dentists, the primary care physician principle does not apply (see clause 1.3).
In the case of treatment by an emergency physician or doctor on call, the invoice must show that the treatment was provided as part of an emergency or on-call service.
Treatment by a physician other than those listed above is considered the same as treatment by the primary care physician, provided that the primary care physician has referred the patient to that physician for co-treatment or further treatment, has confirmed the necessity in writing prior to the co-treatment or further treatment, and the confirmation is submitted for reimbursement together with the bill from the other physician.
The referral by the primary care physician is valid until the completion of the advised treatment, but for no longer than six months. If the need for co-treatment or further treatment persists thereafter, a new referral by the primary care physician is required.
If another physician is seen directly without a prior referral from the primary care physician, the benefit amount for that treatment is reduced under the respective tariff. For future treatment – even for the same insured event – a referral from the primary care physician may be obtained regardless of the above.
The following expenses are covered in the event of outpatient medical treatment, preventive medical examination, childbirth or miscarriage:
- Consultations, visits and procedures including operations;
- targeted preventive medical examinations for the early detection of diseases under statutory programs (targeted preventive examinations) without taking into account the age restrictions specified therein and within the framework of the “Maternity Guidelines”;
- medically prescribed prescription-only drugs;
- medically prescribed nonprescription drugs which, according to the drug guidelines of the Federal Joint Committee (G-BA), may, by way of exception, be prescribed at the expense of the German compulsory health insurance system; tonics, other nutrients, cosmetic products as well as products which, according to their purpose, also serve the individual lifestyle (e.g., potency enhancers, weight reducers, hair restorers) are not considered drugs.
- medically prescribed dressing materials. This also includes stoma and tracheostoma dressings and incontinence products (absorbing and collecting products);
- protective vaccinations advised and carried out by a doctor; reimbursable are, for example, the expenses for protective vaccinations in accordance with the recommendations of the Standing Committee on Vaccination (STIKO) at the Robert Koch Institute (RKI). Vaccines are considered medicinal products within the scope described above. The policy does not cover occupational vaccinations and vaccinations for private trips abroad;
- X-ray, radium and isotope services;
- flat rates for emergency medical services, including travel expenses.
In case of outpatient treatment abroad, the primary care physician model and the restrictions on
- targeted preventive examinations for the early detection of diseases under statutory programs and
- prescription drugs do not apply.
For psychotherapeutic treatment by physicians, clause 1.1 c) applies.
Fees are refundable up to the maximum rate within the currently valid German medical fee schedule (GOÄ). The maximum rate is understood to be 2.3 times the rate of the GOÄ, for services under paragraphs A, E or O of the GOÄ 1.8 times the rate and for services under paragraph M 1.15 times the rate.
Reimbursement for treatment and prescriptions is
- 100% by the primary care physician or an equivalent physician;
- 75% by another physician consulted directly without referral from the primary care physician;
- 100% of eligible expenses abroad (but see clauses 4.13 and 4.15).
b) Services provided by midwives and male midwives
Insurance coverage includes services provided by midwives and male midwives as part of prenatal care/postnatal care, childbirth and miscarriage.
Fees are refundable to the extent of the tariff within the applicable German fee schedules for midwives.
Reimbursement is 100% of refundable expenses.
c) Psychotherapeutic treatment
Psychotherapeutic treatment (including psychological diagnosis) is refundable.
Fees are reimbursable up to the maximum rate within the currently valid German medical fee schedule (GOÄ). The maximum rate is understood to be 2.3 times the rate of the GOÄ, for services under paragraphs A, E or O of the GOÄ 1.8 times the rate and for services under paragraph M 1.15 times the rate.
Reimbursement will continue to be made for psychotherapeutic services within the German fee schedule for psychological psychotherapists and child and adolescent psychotherapists (GOP) that are provided by psychological psychotherapists who have received their license to practice on the basis of training comparable to that of medical psychotherapists.
For children and adolescents, treatment may also be provided by a licensed child and adolescent psychotherapist.
A prerequisite for reimbursement is that a duly substantiated report is submitted to the insurer prior to the start of treatment and that the insurer has agreed to provide the services in writing.
Reimbursement is 75% of refundable expenses.
All remedies recognized in the German state aid rules (BhV) are considered remedies. These include, for example, light, heat and other physical treatments, occupational therapy, speech therapy, massages and medicinal baths. Expenses for sauna, hot air and steam baths and similar baths are not reimbursed. If remedies are administered by non-medical providers of remedies (e.g., physiotherapists), the fees are refundable up to 1.1 times the maximum eligible amounts set by the Federal Minister of the Interior; midwife services within the applicable German fee schedules for midwives.
Reimbursement is 100%.
e) Medical aids
Eligible expenses are those for the supply of medical aids listed in the current list of aids of German compulsory health insurance, each in standard design, including expenses for repair, maintenance and instruction in their use. Medical aids must be prescribed by a physician. Oxygen concentrators, liquid oxygen, ventilators, cardiac and respiratory monitors, and pulse oximeters will be refunded or provided by the insurer upon prior approval of benefits.
Not eligible for reimbursement are visual aids (e.g., electronic readers), nursing aids (e.g., adaptive aids, bathing aids, mobility aids, toilet aids, stairlifts, nursing aids to facilitate care, for hygiene purposes, more independent living, relief of ailments), equipment related to fitness and wellness, radiotherapy equipment, sanitary or medical-technical supplies (e.g., thermometers, heating pads) and operating and care costs (e.g., electricity, batteries, cleaning and care products).
Important: In the case of aids whose expenses are expected to exceed an invoice amount of €500, a cost estimate must be submitted to the insurer before the aids are purchased. The insurer will then check in suitable cases whether this or a comparable aid of the same quality and design can be obtained on more favorable terms than those shown in the cost estimate (less expensive supplies). If this is not the case, expenses are 100% refundable and will be reimbursed at the percentages listed below. However, if less expensive supplies are available and the insured person does not make use of this, the expenses are 75% refundable and will be reimbursed at the percentages stated below. This does not apply if the policyholder states and proves that the supplies offered by the insurer are not suitable in the specific case or cannot be obtained in time in urgent cases (emergency, accident).
If no estimate is submitted in advance for anticipated expenses of more than €500, 75% of the expenses are eligible for reimbursement and will be reimbursed at the percentages listed below.
Reimbursement is 100% of the eligible expenses for each medical aid.
The expenses for glasses and contact lenses (also for a refraction test by an optician) are covered up to an invoice amount of €100. A right to benefits for the renewed purchase of a visual aid arises after two years since the last purchase. Before the expiration of two years, a renewed entitlement to a visual aid arises in the event of a measured change in visual acuity of at least 0.5 diopters.
f) Outpatient transports
Refundable expenses are those for necessary transportation to a physician or hospital for initial care following an emergency or accident.
Also refundable are:
- transports to the nearest suitable doctor or hospital if specialist care or the special facilities of an ambulance are required during the transport;
- transfer to another hospital if this is necessary for compelling medical reasons or, with the prior written consent of the insurer, transfer to a hospital located nearby;
- transports for outpatient medical treatment if the insurer has previously issued a written guarantee of performance.
Reimbursement is 100% of refundable expenses.
g) Home nursing care
Refundable are expenses for medically prescribed home nursing care in accordance with the guidelines of the Federal Joint Committee (G-BA) by suitable qualified nurses, provided that no other person living in the household can perform the measures.
Insurance coverage includes:
- measures of medical treatment that serve to cure illnesses, prevent their worsening or alleviate symptoms of illness and which can usually be delegated to nurses/nursing staff (medical nursing). In particular, this also includes individual medical diagnostic or medical therapeutic services as well as psychiatric nursing care and intensive medical nursing;
- basic activities of daily living (basic care) and domestic care for a period of up to four weeks, insofar as the home nursing care is provided to avoid a hospital stay (hospital avoidance care).
Provided that the service provider (e.g., outpatient nursing service, community health care center) has concluded a corresponding care contract with the compulsory health insurance providers and charges for the services in accordance with the associated remuneration agreement.
Reimbursement is 100% of refundable expenses.
1.2 Inpatient treatment
In the event of inpatient treatment, childbirth or miscarriage, the insurance policy covers hospital expenses for board and lodging, treatment and necessary transportation to the hospital.
The following expenses are refundable:
a) general hospital services;
b) separately billed services by a Belegarzt (attending physician allowed to occupy some beds in a hospital with his patients);
c) inpatient midwife/male midwife;
d) necessary transportation to and from the hospital.
Reimbursable costs are those for general hospital services in accordance with the Federal Regulation of Hospital Nursing Rates (section 7, 8 BPflV) or the Hospital Remuneration Act (section 7 KHEntgG). This includes:
- daily hospital charges;
- flat rates per case;
- additional remunerations;
- separately billable services of an attending physician (Belegarzt) or an inpatient midwife/male midwife;
- pre- and post-inpatient treatment (as defined in section 115a SGB V).
The following is not covered by the insurance: expenses
- for optional services (section 17 KHEntgG or section 16 BPflV);
- for inpatient spa or sanatorium treatment;
- for material and laboratory costs in connection with necessary inpatient dental treatment, dentures or orthodontics.
Insofar as hospitals do not bill in accordance with the Bundespflegesatzverordnung (Federal Healthcare Tariff Law, BPflV) or the Krankenhausentgeltgesetz (German Hospital Fees Act, KHEntgG), expenses for general hospital services are reimbursed within the framework of the tariff up to the amount that would have been incurred in accordance with BPflV or KHEntgG.
Expenses for board and lodging as well as care of a healthy newborn are considered incurred on behalf of the mother. They are reimbursed to the extent of the tariff together with the costs of childbirth. Fees for attending physicians/anesthetists are refundable up to the maximum rate within the currently valid German medical fee schedule (GOÄ). The maximum rate is understood to be 2.3 times the rate of the GOÄ, for services under paragraphs A, E or O of the GOÄ 1.8 times the rate and for services under paragraph M 1.15 times the rate.
Reimbursement is 100% of refundable expenses.
1.3 Dental treatment, dental prophylactic measures and dentures
The primary care physician principle (see clause 1.1) does not apply for dentists. Insurance coverage includes expenses for
a) dental treatment (e.g., fillings except inlays, extractions, root canal treatments, diseases of the oral mucosa and periodontium).
Fees are refundable up to the maximum rate within the currently valid German medical fee schedule (GOÄ) or German dental fee schedule (GOZ).
The reimbursement amounts to 100% of the refundable expenses up to €500 per insurance year, or 50% of the expenses exceeding this amount per insurance year.
b) dental prophylactic measures, e.g.:
- preparation of oral hygiene status, as well as detailed examination for dental, oral and jaw diseases, as well as assessment of oral hygiene and gum condition and control of the success of the exercise, including further instructions;
- education about causes of disease of the teeth and their prevention;
- fluoridation to harden the enamel;
- removal of plaque and discoloration (this does not include the so-called professional teeth cleaning or bleaching);
- treatment of hypersensitive tooth surfaces;
- fissure sealing.
Fees are refundable up to the maximum rate within the currently valid German medical fee schedule (GOÄ) or German dental fee schedule (GOZ). The maximum rate is understood to be 2.3 times the rate of the GOÄ, for services under paragraphs A, E or O of the GOÄ 1.8 times the rate and for services under paragraph M 1.15 times the rate.
Reimbursement shall be made within the scope of the compensation limitation in accordance with clause 1.3 a).
c) dentures and orthodontics
Dentures are considered to be:
Prosthetic services including crowns and inlay fillings (also for the restoration of a single tooth) as well as the insertion of occlusal and other splints, functional analysis and functional therapy services.
Dental implants are not considered to be dentures.
Furthermore, dental laboratory work and materials are refundable within the scope of this medically necessary treatment, insofar as they are listed in the insurer’s list of prices and services*) and are charged within the limits of the maximum amounts specified therein.
If the insured event is caused by an accident after the start of insurance coverage, the costs of medically necessary dentures will be reimbursed at 100% up to a maximum of €2,500 within two calendar years. However, damage to teeth due to chewing food/objects and biting is not considered an accident.
Benefits for orthodontic treatment can only be claimed by an insured person who has not reached the age of 18 at the time treatment begins. Benefits for orthodontic treatment will only be provided if the insured person submits a treatment and cost plan to the insurer prior to the start of treatment, which includes in particular comprehensive information on the findings and the planned treatment in terms of type, scope and costs. The insurer will review the plan and provide the insured person with written information about the expected benefit.
The reimbursement amounts to 50% of the eligible expenses, max. €500 per insurance year.
At the start of insurance, a waiting period of 8 months is agreed for dentures and orthodontics (see section 3 par. 3 AVB/Impats).
1.4 Costs for return transport and transport of mortal remains
a) the medically necessary and medically ordered return transport of the patient from the Federal Republic of Germany to the home country of the insured person, if the medically necessary inpatient treatment would exceed a period of two weeks due to the nature and severity of the illness or the consequences of the accident, or if the insurer has agreed to refund the costs. The additional costs of the return transport are refundable. Additional costs within the meaning of these conditions are the additional costs incurred for a return to the home country due to the occurrence of the insured event.
b) (in the event of death) the burial in the area of validity in accordance with section 1 par. 4 or the transport of mortal remains to the permanent residence of the insured person up to €30,000.
1.5 Follow-up treatment
Refundable is the medically necessary inpatient follow-up treatment (AHB) that was commenced within two weeks of the acute inpatient treatment and was medically necessary due to one of the following indications: heart bypass surgery, acute myocardial infarction, open heart surgery, spinal surgery, stroke, joint replacement with knee or hip joint prostheses, nailing of femoral fractures or malignant neoplasm (follow-up treatment after surgery, chemotherapy or radiation therapy), provided there is no claim against another health insurer.
This also applies if this treatment is carried out in a spa or sanatorium.
Reimbursement is 100% of refundable expenses.
1.6 Outpatient rehabilitation
Expenses for outpatient rehabilitation measures are refundable if the other insured benefits listed above are not sufficient to achieve the medically necessary treatment objective.
Entitlement to outpatient rehabilitation measures is limited to a maximum of 20 days of treatment, unless an extension is urgently required for medical reasons. Two outpatient rehabilitation measures must be at least four years apart. This four-year period is not affected by a change of insurer in the meantime. Upon request of the insurer, the insured person is obliged to provide proof of having used the measures.
1.7 Daily hospital allowance
From the 15th day of a medically necessary hospital stay, a daily hospital allowance of €30 per day is paid without proof of costs. The maximum benefit period is 20 days per calendar year.
1.8 Convalescence allowance
The insurer shall pay a convalescence allowance of €1,500 per insured event upon application if
a) the insured person is unable to work immediately following medically necessary inpatient treatment of at least 14 calendar days
b) the periods of medically necessary inpatient treatment and the subsequent medically confirmed inability to work together amount to at least 90 calendar days.
The day of admission and the day of discharge of the medically necessary inpatient treatment shall each be deemed to be one day. Payment of the convalescence allowance is not due before all of the above benefit requirements have been met.
1.9 Inpatient hospice services
Coverage includes expenses for inpatient or partial inpatient care in a registered hospice where palliative medical treatment is provided if the insured person does not require hospital treatment and outpatient care cannot be provided in the insured person’s household or family.
Fees are refundable up to the amount that would be expended for the care of an insured person covered by compulsory health insurance.
Reimbursement is 100% of refundable expenses.
An annual deductible shall be deducted from the tariff benefits under clauses 1.1 to 1.9. For each insurance year, it amounts to the following maximum per insured person
for benefit level 1: €0,
for benefit level 2: €300.
The deductible refers to the total amount to be refunded in an insurance year for the insured person.
2. Changes of and additions to the General Insurance Conditions (AVB/Impats)
2.1 Insurance coverage
Regarding section 3 par. 2 AVB/Impats: Waiting periods
In deviation from section 3 par. 2 AVB/Impats, the general waiting period does not apply
- even if the DR-WALTER come-in tariff is taken out prior to entry into Germany,
- in the event of withdrawal from a previous insurance policy,
- if insurance coverage is to commence immediately thereafter, in the event of the following acute infectious diseases: rubella, measles, chickenpox, scarlet fever, diphtheria, pertussis, mumps, polio, meningism, dysentery, paratyphoid fever, typhoid fever, spotted fever, cholera, smallpox, malaria and relapsing fever.
Regarding section 4 par. 1 AVB/Impats: Scope of benefits to be paid for treatment abroad
By way of derogation from section 4 par. 13 AVB/Impats, in the case of treatment abroad, the refundable expenses will be reimbursed to the extent stipulated in the tariff in accordance with the costs that are common in that region.
2.2 Obligations of the policyholder
Regarding section 8 par. 1 AVB/Impats: Determination of the premium
The premium for the 0 – 18, 18 – 30, 30 – 46 or 46 – 60 age groups is valid until the end of the month in which you reach the age of 18, the age of 30, the age of 46 or the age of 60, respectively. After that, the premium of the next age group is to be paid.
2.3 End of insurance coverage
Regarding section 15 par. 4 AVB/Impats: Other reasons for termination
If the insurance of individual insured persons ends (see section 15 par. 1 to 3 AVB/Impats), these persons have the right to continue the insurance – provided that the respective tariff requirements are met – in tariff eins A Prima 1 without another medical examination.
General Insurance Conditions for Temporary Stays in Germany (AVB/Impats).
As of 01 April 2021
Section 1 Subject matter, scope and area of validity of the insurance coverage
(1) The insurer provides coverage for illnesses, accidents and other events specified in the contract. The insurer shall provide directly related additional services, if agreed. In the event of an insured event, the insurer shall reimburse expenses for medical treatment and other agreed benefits.
(2) An insured event is the medically necessary treatment of an insured person due to illness or as the result of an accident. The insured event begins with the medical treatment; it ends when, according to medical findings, the need for treatment no longer exists. If the treatment has to be extended to an illness or consequence of an accident that is not causally related to the illness or consequence previously treated, this constitutes a new insured event in this respect. Insured events include
a) examination and medically necessary treatment due to pregnancy and childbirth,
b) outpatient examinations for the early detection of diseases according to statutory programs (targeted preventive medical examinations),
c) the non-illegal termination of pregnancy in accordance with section 218a (2) and (3) of the German Criminal Code (see annex) by a physician, including in each case legally prescribed assessment and counseling services. To ensure the insured person’s right to self-determination, billing is done directly with the service provider at the insured person’s express request and without issuing a formal benefit statement to the policyholder. The benefits are generally not taken into account when calculating any agreed annual deductible.
(3) The scope of insurance coverage is determined by the insurance policy, subsequent written agreements, the General Terms and Conditions of Insurance, and statutory regulations. The insurance contract is subject to German law.
(4) Insurance coverage extends to the geographical area of Europe. In addition, insurance coverage is provided during the first month of a temporary stay in a non-European country.
(5) If an insured person transfers his/her habitual residence to another member state of the European Union, to another contracting state of the Agreement on the European Economic Area or to Switzerland, the insurance contract shall continue provided that the insurer shall remain obligated at most to provide those benefits which he would have been obligated to provide if the insured person had resided in Germany.
Section 2 Start of insurance coverage
(1) The insurance cover shall commence at the point in time specified in the insurance policy (start of insurance), but not before conclusion of the insurance contract (in particular receipt of the insurance policy or a written declaration of acceptance). Insured events that took place prior to the start of the insurance coverage are not covered. Insured events occurring after the conclusion of the insurance contract are excluded from the liability to pay benefits only for the part that falls into the period before the start of the insurance.
In the event of amendments to the contract, sentences 1 to 3 shall apply to the added part of the insurance coverage.
(2) The provisions on the start of insurance coverage shall apply accordingly in the case of subsequent co-insurance of persons and in the case of an increase in insurance coverage.
(3) In the case of newborns, insurance coverage begins without risk premiums and without waiting periods with the completion of birth if one parent is insured with the insurer on the day of the birth and the application for insurance is made retroactively no later than two months after the day of the birth. Coverage may not be higher or more comprehensive than that of a covered parent.
(4) For newborns who are co-insured from birth in accordance with paragraph 3, insurance coverage is also provided from birth for all health impairments, birth defects and congenital diseases and anomalies arising before the completion of birth.
(5) The birth of a child is equivalent to adoption, provided that the child is still a minor at the time of adoption.
(6) For newborns or adopted children who are co-insured in accordance with paragraphs 2 or 3, a lower deductible than for the insured parent can also be agreed upon at the conditions specified in section 2 par. 2, 3 and 4.
Section 3 Waiting periods
(1) Waiting periods are calculated from the start of the insurance.
(2) The general waiting period is three months. It does not apply to
b) the spouse or the civil partner in accordance with section 1 of the Law on Civil Partnership (LPartG) of a person who has been insured for at least three months, provided that a similar insurance policy is applied for within two months of the marriage or registration of the civil partnership.
(3) The special waiting periods are eight months for childbirth, psychotherapy, dental treatment, dentures and orthodontics.
Section 4 Scope of the liability to pay benefits
(1) Fees are refundable to the extent of the tariff within the applicable German fee schedules. In the case of Centers for Social Pediatrics, the flat rates agreed with the health insurers are also refundable.
In case of a temporary stay abroad, fees are refundable to the extent of the tariff within the applicable German fee schedules.
(2) The insurer shall pay to the contractual extent for examination or treatment methods and medicines that are predominantly recognized by conventional medicine. The insurer will also pay for methods and medicines that have proven equally promising in practice or which are used because no conventional medical methods or medicines are available; however, the insurer may reduce his benefits to the amount that would have been incurred if available conventional medical methods or medicines had been used.
(3) If the costs of medical treatment are expected to exceed €2,000, the policyholder may request information in writing about the scope of insurance coverage for the intended medical treatment before treatment begins. The insurer shall provide the information after four weeks at the latest; if the medical treatment is urgent, the information shall be provided immediately, after two weeks at the latest. The insurer will respond to a submitted estimate of cost and other documentation. The period begins with the insurer’s receipt of the request for information. If the information is not provided within the time limit, it is presumed that the intended medical treatment is necessary until the insurer proves otherwise.
(4) At the request of the policyholder or the insured person, the insurer shall provide them with information on expert opinions or statements and allow them to inspect these documents, which the insurer has obtained when assessing the liability to pay benefits regarding the necessity of medical treatment. If there are substantial therapeutic reasons or other substantial reasons against providing information to the policyholder or the insured person, or against their inspection of said documents, it may only be requested that a designated physician or attorney be provided with information about the documents or inspect them. The claim can only be asserted by the respective person concerned or his/her legal representative. If the policyholder has obtained the expert opinion or statement at the instigation of the insurer, the insurer shall reimburse the costs incurred.
(5) Provided that the insured person has no other entitlement to reimbursement of expenses or benefits in kind, costs will be covered for a total of three outpatient or inpatient withdrawal treatments if there is a prospect of success.
Even in case of multiple addictions, the insured person is entitled to no more than three withdrawal treatments. If withdrawal treatments are fully covered by another health insurer, they will be taken into account when calculating the total of three eligible withdrawal treatments.
Subject to the aforementioned conditions, the costs of withdrawal treatments carried out due to non-substance-related addictions (e.g., internet addiction, gambling addiction) are also covered.
Expenses for optional services are not refundable.
Section 5 Limitation of the liability to pay
(1) There is no liability to pay
a) for illnesses including their consequences as well as for consequences of accidents and for deaths caused by war;
in the case of war, no liability to pay benefits exists only for such illnesses and their consequences as well as for consequences of accidents and for deaths caused by active participation in war.
Terrorist attacks and their consequences do not count as events of war.
Damages suffered during military service that occur after the start of the insurance will be paid subject to paragraph 3.
b) for illnesses and accidents based on intent, including their consequences;
c) for treatment by physicians, midwives or male midwives, as well as licensed psychotherapists working in their own practice and entered in the medical register, and in hospitals whose invoices the insurer has excluded from reimbursement for good cause if the insured event occurs after the policyholder has been notified of the exclusion of benefits. If an insured event is pending at the time of notification, there is no liability to pay benefits for expenses incurred after three months have elapsed since notification;
d) for spa and sanatorium treatment or for rehabilitation measures of the compulsory rehabilitation providers;
e) for treatment by spouses, civil partners in accordance with section 1 of the Law on Civil Partnership (LPartG) (see annex), parents or children. Proven material costs will be refunded in accordance with the tariff;
f) for placement due to need of care or custody;
g) for additional costs of medical treatment abroad, provided that the insured person has traveled abroad for the purpose of medical treatment. Additional costs are defined as those parts of the costs of treatment abroad that exceed the benefits agreed in the tariff for adequate treatment in Germany. In any case, reimbursement will not exceed the actual refundable expenses incurred.
This restriction does not apply to
- childbirth when one of the parents is a national of the country of residence. The prerequisite is that the policyholder provides proof of citizenship
- in case of medically necessary treatment abroad that would not have been feasible in Germany, or would only have been partially feasible,
- if in the context of an accident, i.e., treatment that cannot be planned, a foreign hospital is the nearest suitable place of treatment.
(2) If a medical treatment or other measure for which benefits have been agreed exceeds what is medically necessary, the insurer may reduce his benefits to a reasonable amount. If the expenses for the medical treatment or other services are conspicuously disproportionate to the services provided, the insurer is not obliged to pay benefits in this respect.
(3) If there is also an entitlement to benefits from compulsory accident insurance or social security pension insurance, to compulsory medical care or accident care, the insurer is only liable to pay for the expenses which remain necessary despite the statutory benefits.
(4) If the insured person has a claim against more than one party liable to refund costs due to the same insured event, the total reimbursement may not exceed the total expenses.
Section 6 Payment of benefits
(1) The insurer is only liable to pay premiums if the evidence required by him is provided; such evidence becomes the property of the insurer.
The insurer is liable to pay to the insured person if the policyholder has named this person in writing as the person authorized to receive his/her insurance benefits. If this condition is not met, only the policyholder can claim the benefit.
(2) In each case, the expenses are counted in the calendar year in which the treatment occurred or the funds were received. The expenses must be proven by the originals of the invoices or by copies of the invoices confirming the benefits provided by other insurers or health insurers. Medical bills must include:
- name of the treated person,
- designation of all diseases,
- information about the individual medical services with clauses of the applied fee schedule,
- treatment data.
The evidence should be submitted no later than March 31 of the year following the medical treatment.
(3) In all other respects, the conditions for the due date of the insurer’s benefits are derived from section 14 VVG (see annex).
(4) Costs incurred in a foreign currency are converted into euros at the current exchange rate on the day the receipts are received by the insurer. The rate of the day is the official euro exchange rate of the European Central Bank. For non-traded currencies for which no reference rates have been fixed, the rate according to “Exchange Rate Statistics”, published by the Deutsche Bundesbank, Frankfurt/Main, shall apply according to the latest status, unless the insured person proves by bank receipt that he/she has acquired the foreign currencies required for payment of the invoices at a less favorable rate.
(5) Costs for translations are not deducted from the benefits. Costs for transfer of insurance benefits will be deducted from the benefits only if they are incurred because the insurer makes bank transfers abroad at the policyholder’s request or chooses special forms of bank transfer.
(6) Claims to insurance benefits may neither be assigned nor pledged.
(7) If an insurance card has been issued on the basis of which it is possible to bill a service provider directly, the non-assignment clause does not apply in this respect.
Section 7 End of insurance coverage
The insurance coverage also ends for pending insured events – for the insured person
- with the termination of the agreed tariff for temporary stays in Germany,
- with the granting of an unlimited residence permit in Germany,
- but at the latest with the expiry of the maximum insurance period of five years (section 195 par. 3 VVG, see annex). If the insured person already had temporary health insurance for the existing stay in Germany with another insurer before taking out this tariff, the insurance period completed there will be taken into account when calculating the maximum insurance period mentioned above.
Section 15 (1) to (3) stipulates when the insurance contract ends. It may be continued under the conditions specified in section 15 par. 4.
OBLIGATIONS OF THE POLICYHOLDER
Section 8 Payment of premiums
(1) The premium is a monthly premium. The first month of insurance begins on the date specified in the insurance policy. The premium is payable in advance and is due on the day of the beginning of the first month.
(2) If the insurance contract is applied for later than one month after the obligation to insure has arisen, a premium surcharge in the amount of one monthly premium shall be paid for each additional month or part thereof of non-insurance, and from the sixth month of non-insurance, one sixth of the monthly premium shall be paid for each additional month or part thereof of non-insurance. If the duration of non-insurance cannot be determined, it shall be assumed that the insured was uninsured for at least five years. The premium surcharge is payable once in addition to the current premium. The policyholder may request the insurer to defer the premium surcharge if the interests of the insurer can be taken into account by agreeing on an appropriate installment payment. Interest is paid on the deferred amount.
(3) The first premium or premium installment shall be paid immediately after conclusion of the insurance contract, irrespective of the existence of a right to revoke.
(4) If the policyholder is in default with an amount equivalent to two months’ premiums, the insurer shall send him/her a reminder. For each month or part thereof of default, the policyholder shall pay a late payment surcharge of 1% of the default premium as well as reminder costs in the proven amount. If, two months after receipt of this reminder, the default premium (including late payment surcharges) is still higher than the premium amount for one month, the insurer shall send a second reminder with reference to the possible suspension of the insurance contract. If, one month after receipt of the second reminder, the default premium including late payment surcharges is higher than the premium amount for one month, the insurance contract shall be suspended as of the first day of the following month. As long as the insurance contract is suspended, the insured person shall be deemed to be insured under the emergency tariff in accordance with section 153 VAG (see annex). In this respect, the General Insurance Conditions for the emergency tariff (AVB/NLT) shall apply in the currently valid version.
The insurance contract shall not be suspended or its suspension shall end if the policyholder or the insured person is or becomes in need of assistance within the meaning of Book 2 or Book 12 of the German Social Code. Notwithstanding the foregoing, the contract shall be continued from the first day of the month after next in the tariff in which the policyholder or the insured person was insured prior to the occurrence of the suspension, if all default premium amounts, including late payment surcharges and collection costs, have been paid. In the cases of sentences 7 and 8, the policyholder or the insured person shall be placed in the same position as the policyholder or the insured person was in prior to the insurance in the emergency tariff in accordance with section 153 VAG (see annex). Premium adjustments and amendments to the General Insurance Conditions made during the period of suspension in the tariff in which the policyholder or the insured person was insured prior to the commencement of suspension shall apply from the date of continuation of insurance in that tariff.
The need for assistance must be evidenced by a certificate issued by the competent institution in accordance with Book 2 or Book 12 of the German Social Code; the insurer may request the submission of a new certificate at reasonable intervals.
(5) If the insurance contract is terminated before the expiry of the contract period, the insurer is only entitled to that part of the premium or premium installment which corresponds to the period during which the insurance coverage existed. If the insurance contract is terminated by withdrawal on the basis of section 19 (2) VVG (see annex) or by rescission of the insurer due to fraudulent misrepresentation, the insurer shall be entitled to the premium or premium installment until the declaration of withdrawal or rescission takes effect. If the insurer withdraws because the first premium or premium installment is not paid on time, he may charge a reasonable service fee.
(6) The premiums shall be paid to the office to be designated by the insurer.
Section 8a Premium calculation
The calculation of premiums is carried out in accordance with the provisions of the Insurance Supervision Act (VAG) and is specified in the insurer’s documents and data for premium calculation. No old-age provisions will be made.
Section 8b Premium adjustment
(1) Under the contractual guarantee of performance, the insurer’s benefits may change, for example, due to rising medical treatment costs, more frequent utilization of medical services or due to increasing life expectancy. Accordingly, the insurer compares the required insurance benefits with those calculated in the documents and data for premium calculation at least annually for each tariff. If this comparison for one of the categories children, adolescents or adults (the so-called observation units) in a tariff results in a deviation of more than the percentage specified by law or by the tariff, all premiums for the affected observation unit shall be reviewed by the insurer and, if necessary, adjusted with the approval of the trustee. Under the same conditions, a deductible fixed in terms of amount may also be adjusted and an agreed risk surcharge changed accordingly. In the course of a premium adjustment, the surcharge required for slowing the increase of premiums in the basic tariff (section 20 sentence 2) shall also be compared with the respective calculated surcharges and, if necessary, adjusted.
(2) If the comparison of the required insurance benefits with those calculated in the documents and data for premium calculation in accordance with par. 1 shows a deviation of more than 5%, the premiums shall be reviewed by the insurer and, if necessary, adjusted with the consent of the trustee.
(3) A premium adjustment may be waived if, in the concurring judgment of the insurer and the trustee, the change in insurance benefits is to be regarded as temporary.
(4) The insurer will refrain from adjusting the premium if the requirements of par. 3 are met.
(5) Premium adjustments as well as changes to deductibles and any agreed risk surcharges shall take effect at the beginning of the second month following notification of the policyholder.
Section 9 Obligations
(1) At the request of the insurer, the policyholder and the insured person authorized to receive the benefits (see section 6 par. 1) must provide any information required to determine whether an insured event has occurred or whether the insurer is obliged to pay benefits and the extent of this obligation.
(2) At the request of the insurer, the insured person is obliged to be examined by a doctor appointed by the insurer.
(3) The insured person shall, as far as possible, take care to mitigate the damage and refrain from all actions that impede recovery.
(4) If a comprehensive health insurance contract is concluded for an insured person with another insurer or if an insured person makes use of the entitlement to insurance in the compulsory health insurance, the policyholder is obliged to inform the insurer about the other insurance without delay.
(5) The policyholder must notify the insurer without delay that the insured person is no longer eligible for insurance due to the conversion of his/her residence permit into an unlimited permit for Germany.
Section 10 Consequences of a breach of obligations
(1) The insurer shall be wholly or partially exempt from the obligation to perform, subject to the restrictions prescribed in section 28 par. 2 to 4 VVG (see annex), if one of the obligations specified in section 9 par. 1 to 5 is breached.
(2) The knowledge and fault of the insured person are equivalent to the knowledge and fault of the policyholder.
Section 11 Obligations and consequences of a breach of obligations in the event of claims against third parties
(1) If the policyholder or an insured person has claims for compensation against third parties, there is, irrespective of the legal subrogation in accordance with section 86 VVG (see annex), the obligation to assign these claims to the insurer in writing up to the amount in which compensation (reimbursement of expenses as well as material and services) is paid under the insurance contract.
(2) The policyholder or the insured person has to assert his/her claim for compensation or any right to secure this claim properly and in due time and assist the insurer, as far as necessary, in enforcing such claim for compensation.
(3) If the policyholder or an insured person intentionally breaches the obligations set out in paragraphs 1 and 2, the insurer is not obliged to perform to the extent that he cannot obtain compensation from the third party as a result. In case of a grossly negligent breach of obligations, the insurer is entitled to reduce his benefits according to the severity of the fault.
(4) If the policyholder or an insured person has a claim for repayment of charges paid without legal cause against the provider of benefits for which the insurer has provided reimbursement on the basis of the insurance contract, paragraphs 1 to 3 shall apply accordingly.
(5) If, in the event of an insured event, claims exist against another insurer on the basis of an international health insurance policy, the latter’s liability to pay benefits shall take precedence. This also applies if only subordinated liability has been agreed in the international health insurance contract. This only affects the settlement between insurers. This means that the policyholder does not have to hold the other insurer liable first.
Section 12 Set-off
The policyholder may only set off against claims of the insurer if the counterclaim is undisputed or has been legally established.
END OF INSURANCE COVERAGE
§ 13 Termination by the policyholder
(1) The policyholder may terminate the insurance contract without notice at the end of every month. The termination shall take effect on the first day of the following month. If the insurance contract serves the fulfillment of the obligation to insure (section 193 par. 3 VVG – see annex), the termination in accordance with par. 1, 2, 4, 5 and 6 requires that a new contract be concluded for the insured person with another insurer that meets the requirements for the obligation to insure. The termination shall only take effect if the policyholder proves within two months after the notice of termination that the insured person is insured with a new insurer without interruption; if the date on which the notice of termination was given is more than two months after the notice of termination, the proof must be provided by that date.
(2) The first insurance year begins at the start of the insurance contract specified in the insurance policy. Changes in the insurance contract do not affect the start and end of the insurance year.
(3) Termination may be limited to individual insured persons or tariffs.
(4) If an insured person is required by law to be insured under the compulsory health insurance system, the policyholder may cancel a health insurance policy or an Anwartschaftsversicherung (insurance for reinstatement of health care coverage after suspension) existing for this purpose within three months of becoming subject to compulsory insurance, with retroactive effect to the date of becoming subject to compulsory insurance. The termination shall be invalid if the policyholder fails to prove the commencement of the insurance obligation within two months after the insurer has requested him/her to do so in writing, unless the policyholder is not responsible for the failure to meet this deadline. If the policyholder exercises his/her right of termination, the insurer is entitled to the premium only until the date on which the insurance becomes compulsory. Later, the policyholder may terminate the health insurance at the end of the month in which he/she proves the commencement of the insurance obligation. In this case, the insurer is entitled to the premium until the end of the insurance contract. The legal entitlement to family insurance or the entitlement, which is not only temporary, to medical care from a civil service or similar employment relationship is equivalent to compulsory insurance.
(5) If an agreement in the insurance contract has the effect that upon reaching a certain age or upon the occurrence of other conditions specified therein, the premium applies to a different age or age group, the policyholder may terminate the insurance contract with respect to the insured person concerned within two months of the change coming into effect if the premium increases as a result of the change.
(6) If the insurer increases the premiums on the basis of the premium adjustment clause or reduces his benefits in accordance with section 18 par. 1, the policyholder may terminate the insurance contract with respect to the insured person concerned within two months of receipt of the notification of change as of the date on which the change takes effect. In the event of a premium increase, the policyholder may also terminate the insurance contract up to and at the time the increase takes effect.
(7) If the insurer increases a deductible fixed in terms of amount on the basis of the premium adjustment clause (§ 8b), the policyholder may terminate the insurance contract with regard to the insured person concerned up to and at the time the change takes effect.
(8) If the insurer declares the rescission, withdrawal or cancellation only for individual insured persons or tariffs, the policyholder can demand the cancellation of the remaining part of the insurance within two weeks after receipt of this declaration at the end of the month in which he/she received the insurer’s declaration, in the case of cancellation at the time when it becomes effective.
(9) If there is a backlog of payments at the time of termination of the insurance contract, the insurer may retain the transfer value until the premium has been paid in full.
(10) If the policyholder terminates the insurance contract as a whole or for individual insured persons, the insured persons have the right to continue the insurance contract, naming the future policyholder, for a maximum of up to the maximum insurance period of five years (section 195 (3) VVG, see annex). The declaration must be submitted within two months of the termination. The termination shall only be effective if the policyholder proves that the insured persons concerned have become aware of the notice of termination.
Section 14 Termination by the insurer
(1) The insurer’s right to terminate at any time is excluded.
(2) The statutory provisions on the right of extraordinary termination shall remain unaffected.
Section 15 Other reasons for termination
(1) The tariff ends at the end of the maximum insurance period of five years. The maximum insurance period begins with the start of insurance agreed for the insured person.
If the insured person already had temporary health insurance for the existing stay in Germany with another insurer in accordance with section 195 par. 3 VVG (see annex) before taking out this tariff, the insurance period completed there will be taken into account when calculating the maximum insurance period stipulated above in sentence 1 of this clause.
(2) The tariff concluded for the insured person ends for him/her with the conversion of his/her residence permit into an unlimited permit for Germany.
(3) If an insured person transfers his/her habitual residence to a country other than those specified in section 1 (5), the insurance relationship shall end in this respect unless it is continued on the basis of another agreement. The insurer may demand an appropriate premium surcharge within the scope of this other agreement.
(4) If the insurance of individual insured persons ends, they have the right to continue the insurance – provided that the tariff requirements for this are met – in accordance with the insurer’s similar unlimited tariffs open for new business. The prerequisite for this is that the continuation of insurance is applied for with the insurer within two months after the end of the insurance for temporary stays in Germany.
In the event of an increase in insurance coverage, risk surcharges or benefit exclusions may be agreed for additional benefits.
In the event of conversion, the period during which the insured person was continuously insured under the insurance for temporary stays in Germany will be taken into account when calculating any waiting periods or time limits.
Section 16 Declarations of intent and notifications
Declarations of intent and notifications to the insurer must be made in writing.
Section 17 Place of jurisdiction
(1) For actions arising from the insurance contract against the policyholder, the court of the place where the policyholder has his/her place of residence or, in the absence of such, his/her habitual residence shall have jurisdiction.
(2) Actions against the insurer may be brought before the court at the policyholder’s place of residence or habitual residence or before the court at the insurer’s registered office.
(3) If, after conclusion of the contract, the policyholder moves his/her place of residence or habitual residence to a state that is not a Member State of the European Union or a Contracting State to the Agreement on the European Economic Area, or if his/her place of residence or habitual residence is unknown at the time the action is brought, the court at the insurer’s registered office shall have jurisdiction.
If the domicile or habitual residence of the policyholder or the insured person is outside the states mentioned in sentence 1, the following regulation shall apply: The place of jurisdiction for all legal disputes between the parties relating to the insurance contract shall be in Wuppertal (registered office of the insurer) or at another place in Germany subject to the German Code of Civil Procedure (ZPO) and the German Courts Constitution Act (GVG).
Section 18 Changes to the General Insurance Conditions
(1) 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 Insurance Conditions 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 that they are appropriate. The changes shall take effect at the beginning of the second month following the notification of the policyholder of the changes and the relevant reasons for such changes.
(2) If a provision in the General Insurance Conditions has been declared invalid by a supreme court decision or by a binding administrative decision, the insurer may replace it with a new provision if this is necessary for the continuation of the contract or if adherence to the contract without a new provision would represent an unreasonable hardship for one party to the contract, even taking into account the interests of the other party to the contract. The new regulation is only effective if it adequately takes into account the interests of the policyholders while preserving the objective of the contract. It shall become part of the contract two weeks after the policyholder has been informed of the new regulation and the relevant reasons for it.
Section 19 Change to the basic tariff
The policyholder may request that insured persons under his/her contract be able to change to the basic tariff with maximum premium guarantee and premium reduction in the event of need for assistance if the existing comprehensive health insurance policy was first taken out on or after January 1, 2009 or if the insured person has reached the age of 55 or has not yet reached the age of 55 but has met the requirements for entitlement to a pension under social security pension insurance and has applied for this pension or receives a pension under civil service law or comparable provisions or is in need of assistance under Book 2 or Book 12 of the German Social Code. To ensure this cap on premiums, the surcharge specified in the documents and data for premium calculation is charged.
The change is possible at any time after fulfillment of the legal requirements; insurance in the basic tariff begins on the first of the month following the policyholder’s application to change to the basic tariff.
GERMAN INSURANCE CONTRACT ACT (VVG)
§ 8 Policyholder’s right of revocation
(1) The policyholder may revoke his contractual agreement within 14 days. The policyholder shall declare his revocation to the insurer in writing, but need not state any reason; timely dispatch shall suffice for compliance with the time limit.
(2) The revocation period shall begin at such time as the policyholder receives the following documents in writing:
1. the insurance policy and the terms of contract, including the general terms and conditions of insurance, as well as the other information in accordance with section 7 (1) and (2), and
2. a clearly worded instruction regarding the right of revocation and the legal consequences of the revocation which makes clear to the policyholder his rights commensurate with the requirements of the means of communication employed, and the names of the person to whom the revocation is to be declared, with an address at which documents may be served, as well as a note making reference to the commencement of the revocation period and to the rules set out in subsection (1), second sentence.
(3) The right of revocation shall not apply
1. to contracts of insurance with a term of less than one month,
2. to contracts of insurance for provisional cover, unless they are distance contracts within the meaning of section 312b (1) and (2) of the German Civil Code,
§ 14 Due date of the payment
(1) Payments of the insurer are due after the end of the assessment required to determine the occurrence of an insured event and the amount of compensation payable by the insurer.
(2) If such assessment is not finished after expiry of one month since the notification of the insured event, the policyholder can request payment by installments amounting to the minimum that the insurer can be expected to be required to pay. The period shall be suspended as long as the assessment cannot be finished due to a fault of the policyholder.
(3) Any agreement under which the insurer is exempt from his obligation to pay default interest shall be invalid.
§ 19 Duty of disclosure
(1) The policyholder shall disclose to the insurer before making his contractual acceptance the risk factors known to him which are relevant to the insurer’s decision to conclude the contract with the agreed content and which the insurer has requested in writing. If, after receiving the policyholder’s contractual acceptance and before accepting the contract, the insurer asks such questions as are referred to in the first sentence, the policyholder shall also be under the duty of disclosure as regards these questions.
(2) If the policyholder breaches his duty of disclosure under subsection (1), the insurer may withdraw from the contract.
§ 28 Breach of a contractual obligation
(1) In case of a breach of a contractual obligation towards the insurer that the policyholder needs to fulfill prior to the occurrence of the insured event, the insurer may cancel the contract without notice within one month from the time he becomes aware of the breach, unless the breach is not the result of intention or gross negligence.
(2) Where the contract stipulates that the insurer is exempt from its liability to pay in case of a breach of a contractual obligation that the policyholder needs to fulfill, the insurer is only exempt from its liability to pay if the policyholder has deliberately breached the obligation. In the event of a grossly negligent breach of the obligation, the insurer shall be entitled to reduce his benefits according to the severity of the fault of the policyholder; the burden of proof for the non-existence of a grossly negligent behavior lies with the policyholder.
(3) By way of derogation from paragraph 2, the insurer is obliged to pay if the breach of the obligation was neither the cause for the occurrence or determination of the insured event nor for the determination or scope of the insurer’s liability to pay. Sentence 1 shall not apply if the policyholder has fraudulently breached the obligation.
(4) Where an obligation to provide information is breached after the occurrence of the insured event, the insurer’s full or partial exemption from performance according to paragraph 2 requires that the insurer has informed the policyholder in writing by separate notification about this legal consequence.
(5) An agreement based on which the insurer is entitled to withdraw from the contract in the event of the non-observance of an incidental obligation shall be void.
§ 37 Delayed payment of first insurance premium
(1) If the single premium or the first premium is not paid in good time, the insurer shall be entitled to withdraw from the contract as long as the payment has not been made, unless the policyholder is not responsible for the non-payment.
(2) If the single premium or first premium has not been paid when the insured event occurs, the insurer shall not be obligated to effect payment, unless the policyholder is not responsible for the non-payment. The insurer shall only be released from liability if he had informed the policyholder of the legal consequence of non-payment of the premium in writing in a separate communication or by means of a conspicuous note in the insurance policy.
§ 38 Delayed payment of subsequent premium
(1) If a subsequent premium is not paid in good time, the insurer may set the policyholder a payment deadline of no less than two weeks at his expense and in writing. The setting of the deadline shall only be effective if it details the individual amounts of the premium which are in arrears, the interest and costs, as well as quoting the legal consequences associated in accordance with subsections (2) and (3)with expiry of the time limit; in the case of consolidated contracts, the amounts must be quoted separately.
(2) If the insured event occurs after the deadline expires, and if the policyholder is in arrears as regards the payment of the premium or of the interest or costs, the insurer shall not be obligated to effect payment.
(3) The insurer may, after the deadline expires, terminate the contract without prior notice insofar as the policyholder is in arrears as regards the payment of the due amounts. The termination can be linked to the setting of the payment deadline in such a way that it becomes effective once the deadline expires if the policyholder is in arrears as regards the payment at that point in time; the policyholder must be explicitly informed of this in the termination. The termination shall become void if the policyholder makes the payment within one month after the contract has been terminated or, if it has been linked to the setting of a deadline, within one month after the deadline expires; subsection (2) shall remain unaffected.
§ 86 Subrogation of claims for compensation
(1) Where the policyholder has a claim for compensation against a third party, the insurer is subrogated to this claim if he compensates the damage. This subrogation cannot be asserted to the policyholder’s disadvantage.
(2) The policyholder has to assert his / her claim for compensation or any right to secure this claim properly and in due time and assist the insurer, as far as necessary, in enforcing such claim for compensation. Where the policyholder breaches this obligation intentionally, the insurer is exempt from his liability to pay insofar as he can consequently not claim compensation from the third party. In case of a grossly negligent breach of obligations, the insurer is entitled to reduce his benefits according to the severity of the policyholder’s fault. The burden of proof for the non-existence of a grossly negligent behavior lies with the policyholder.
(3) If the policyholder’s claim for compensation is against a person with whom he / she lived in cohabitation when the damage occurred, the subrogation in accordance with paragraph 1 cannot be asserted unless this person has intentionally caused the damage.
§ 193 Insured person; obligatory insurance
(1) The health insurance may be taken out for the policyholder or for another person. The insured person shall be that person for whom the insurance is taken out.
(2) Where the knowledge and the conduct of the policyholder are of legal significance under this Act, in the case of insurance for another person, account shall also be taken of the knowledge and conduct of that person.
(3) Each person with a place of residence in Germany shall be obligated to conclude and maintain with an insurance company licensed to operate in Germany for himself and for the persons legally represented by him, insofar as they are not themselves able to conclude contracts, a cost-of-illness insurance which comprises at least a cost refund for outpatient and inpatient treatment and in which the absolute and percentage excesses for outpatient and inpatient treatment which have been agreed for services covered by the respective tariff for each person to be insured are limited to an amount of Euro 5,000 per calendar year; for persons entitled to medical expenses assistance, the possible excesses emerge through the analogous application of the percentage not covered by the rate of medical expenses assistance to the maximum amount of Euro 5,000. The obligation in accordance with the first sentence shall not apply to persons who
1. are insured or subject to obligatory insurance in statutory health insurance, or
2. have a right to free treatment, to medical expenses assistance or to comparable rights to the extent of the respective entitlement, or
3. have a right to benefits in accordance with the Asylum-Seekers Benefits Act, or
4. are recipients of recurrent benefits in accordance with the Third, Fourth and Seventh Chapters of Social Code Book XII, and recipients of benefits in accordance with Part 2 of Social Code Book IX, for the duration of the receipt of such benefits and during periods of an interruption of the receipt of benefits of less than one month if the receipt of benefits commenced prior to 1 January 2009.
A cost-of-illness insurance contract agreed prior to 1 April 2007 shall be deemed to meet the requirements of the first sentence.
§ 194 Applicable provisions
(1) Insofar as the insurance cover is granted in accordance with the principles of indemnity insurance, sections 74 to 80 and sections 82 to 87 shall apply. Sections 23 to 27 and section 29 shall not apply to health insurance. Section 19 (4) shall not apply to health insurance if the policyholder is not responsible for the breach of the duty of disclosure. Notwithstanding section 21 (3), first sentence, the time limit for asserting the insurer’s rights shall be three years.
(2) If the policyholder or an insured person is entitled to the repayment of remuneration paid without legal basis to the provider of services for which the insurer has paid compensation on the basis of the contract of insurance, section 86 (1) and (2) shall apply mutatis mutandis.
(3) Sections 43 to 48 shall apply to health insurance with the proviso that only the insured person may demand payment of the insurance benefit if the policyholder has designated him in writing to the insurer as the beneficiary of the insurance benefit; such designation may be revocable or irrevocable. Where this condition is not met, only the policyholder may demand payment of the insurance benefit. The insurance policy need not be presented.
§ 195 Period of insurance
(1) Health insurance which may wholly or partially substitute for health and long-term nursing care insurance cover provided for in the statutory social insurance system (substitutive health insurance) shall be for an indefinite period, unless subsections (2) and (3) and sections 196 to 199 provide otherwise. Where the non-substitutive health insurance cover is provided in the manner of life insurance, the first sentence shall apply mutatis mutandis.
(2) In the case of vocational training, overseas, travel and residual debt health insurance, a period of contract may be agreed.
(3) In the case of health insurance for a person with a temporary residence permit for Germany, agreement may be reached to the effect that the insurance will expire after five years at the latest. If a shorter term has been agreed, a similar new contract may only be concluded with a maximum term that does not exceed five years when added to the term of the expired contract; this shall also apply if the new contract is concluded with another insurer.
§ 205 Termination of the contract by the policyholder
(3) If the contract of insurance provides that when the policyholder reaches a certain age or when other preconditions referred to therein are met the premium for another age or another age group applies or the premium is calculated taking old age reserves into account, the policyholder may terminate the insurance agreement with regard to the affected insured person within two months after the change with effect from the time it became effective if the premium increases as a result.
(4) If the insurer increases the insurance premium or reduces a benefit on account of an adjustment clause, the policyholder may terminate the insurance policy with regard to the affected insured person within two months after receipt of the communication of the change with effect from such time as the increase in the premium or the reduction of the benefits is to take effect.
§ 213 Collection of personal health data from third parties
(1) The insurer is only allowed to collect personal health data from the following third parties: physicians, any kind of hospitals, nursing homes and staff, other personal insurance providers and providers of compulsory health insurance as well as employers’ liability insurance associations and authorities; such collection of data is only allowed if knowledge of said data is necessary to assess the insured risk or the liability to pay and if the affected party has given his / her declaration of consent.
(2) The declaration of consent in accordance with paragraph 1 can be given prior to issuing the contract statement. The affected person must be informed about data collection as stipulated in paragraph 1 and may object to the collection.
(3) The affected person can request at any time that a collection of data is only carried out if he / she gave his / her consent for each individual data collection.
(4) The affected person must be informed about his / her rights, in particular about the right of objection in accordance with paragraph 2 when being informed about data collection.
GERMAN INSURANCE SUPERVISION ACT (VAG)
§ 153 Hardship tariff
(1) Non-payers within the meaning of section 193 (7) of the German Insurance Contract Act form a tariff within the meaning of section 155 (3) sentence 1. The hardship tariff provides for the reimbursement of expenses solely in connection with benefits necessary for the treatment of serious illness and pain and those associated with pregnancy and maternity. By way of derogation from the above provision, expenses for insured children and young persons, in particular expenses for preventive medical examinations aimed at the early discovery of illnesses under statutory programmes and for immunisation recommended by the German Standing Committee on Vaccination (Ständige Impfkommission – STIKO) at the Robert Koch Institute under section 20 (2) of the German Protection against Infection Act (Infektionsschutzgesetz – IfSG) must be reimbursed.
(2) A standard premium must be calculated for all insured persons under the hardship tariff; section 146 (1) nos. 1 and 2 applies in all other respects. In the case of insured persons whose insurance contract only provides for the reimbursement of a percentage of the expenses incurred, the hardship tariff provides benefits equivalent to 20, 30 or 50 per cent of the insured treatment costs. Section 152 (3) applies, with the necessary modifications. The calculated premiums under the hardship tariff must not exceed the amount required to cover the claims expenditures under the tariff. Additional expenses that arise in connection with guaranteeing the limitations specified in sentence 3 must be allocated equally to all the insurer’s policyholders with an insurance contract that satisfies an obligation under section 193 (3) sentence 1 of the German Insurance Contract Act. The provision for increasing age must be offset against the premium to be paid under the hardship tariff such that up to 25 per cent of the monthly premium is covered by a withdrawal from the provision for increasing age.
GERMAN CRIMINAL CODE (STGB)
§ 218a Exemption from punishment for abortion
(2) A termination which is performed by a physician with the consent of the pregnant woman is not unlawful if, considering the pregnant woman’s present and future circumstances, the termination is medically necessary to avert a danger to the life of or the danger of grave impairment to the pregnant woman’s physical or mental health and if the danger cannot be averted in another manner which is reasonable for her to accept.
(3) The conditions of subsection (2) are also deemed fulfilled with regard to a termination performed by a physician with the consent of the pregnant woman if, according to medical opinion, an unlawful act under sections 176 to 178 has been committed against the pregnant woman, there are cogent reasons to support the assumption that the pregnancy was caused by the act and no more than 12 weeks have elapsed since conception.
GERMAN CIVIL CODE (BGB)
§ 195 Regular limitation period
The regular limitation period is three years.
Data protection notice
a) Data protection principles of DR-WALTER GmbH (hereinafter referred to as DR-WALTER)
The protection of your privacy and of your personal data is paramount to us. We guarantee that we will always treat your data with the utmost confidentiality. Nowadays, insurance companies can only carry out their tasks with the aid of electronic data processing (EDP). Our state-of-the-art EDP enables us to handle contractual relationships correctly, quickly and in a cost-effective manner.
Both our behavior and our tools are in accordance with the General Data Protection Regulation (GDPR), the Federal Data Protection Act (BDSG) as well as with other specific regulations for online data protection. Our data protection officer ensures that our data protection principles and any relating regulations are fully met.
For further information, please go to https://www.dr-walter.com/en/data-protection.html.
b) Information about the use of your data by DR-WALTER
We need your personal data to process your applications and contracts, for claims handling and for individual supervision and consultancy. Collection, processing and use of your data are regulated by law. We have adopted a code of conduct for the handling of personal data that complies with the code of conduct of the German Insurance Association (GDV). Our code of conduct is based on data protection regulations of the German Insurance Contract Act (VVG), the General Data Protection Regulation (GDPR), the Federal Data Protection Act as well as other significant laws but also on further measures to strengthen data protection. For more information, go to https://www.dr-walter.com/en/data-protection/personal-data.html to learn about our code of conduct with regard to handling your personal data.
DR-WALTER cooperates with several service providers in the use of health data and other data protected under § 203 German Criminal Code (StGB). At https://www.dr-walter.com/en/data-protection/list-of-service-providers.html, we provide you with an overview of the service providers we work with. At your request, we can send you a printed list of the service providers as well as our code of conduct. Please contact:
53819 Neunkirchen-Seelscheid, Germany
P +49 (0) 22 47 91 94 -0
F +49 (0) 22 47 91 94 -40
c) Responsible body
Collection of your personal data is carried out by DR-WALTER GmbH, Eisenerzstr. 34, Germany, 53819 Neunkirchen-Seelscheid (responsible body).
d) Your rights
You have the right to obtain information free of charge about your data stored by us. You also have the right to withdraw any granted consent to the collection, processing and use of your personal data at any time and with future effect as well as the right to correct any incorrect data or to delete or block any impermissible or no longer needed data.
You can assert these rights to the above address directly against DR-WALTER. For further questions with regard to data protection, please contact our data protection officer at DR-WALTER, Eisenerzstr. 34, Germany, 53819 Neunkirchen-
Seelscheid, P +49 (0) 22 47 91 94 -0.
List of service providers
In accordance with „Verhaltensregeln für den Umgang mit personenbezogenen Daten durch die deutsche Versicherungswirtschaft“
(Code of Conduct Data Protection)
German insurers have issued a Code of Conduct for the protection of your personal data and your privacy. We, DR-WALTER, comply with this Code of Conduct and would like to provide you with a list of service providers (companies and private individuals) with whom we work together during order processing when it comes to data processing and assignment of functions. The list also includes service providers with whom we cooperate in the use of health data and other data protected under § 203 German Criminal Code (StGB). We also work together with service providers who collect, process and use health data and other data protected under § 203 StGB.
Insurers and reinsurers
Collection, processing or use of personal data to establish, carry out or end an insurance contract (e. g. application processing, risk assessment, policy management, determination of the liability to pay)
Involved bodies / organizations:
Involved bodies / organizations:
Doctors, dentists, psychologists, psychiatrists, experts, other healthcare professionals, institutions for medical examinations, hospitals
Information on treatment and diseases, expert opinions on medical issues
Involved bodies / organizations:
Premium payments, payments in the event of a claim
Involved bodies / organizations:
Legal advice, collections management, legal representation at court.
Involved bodies / organizations:
Market and opinion researchers
Customer satisfaction surveys, market and opinion research
Involved bodies / organizations:
Support and advice e.g. in claims and billing matters (Germany and abroad), fraud detection, health programs; IT services
Involved bodies / organizations:
IT and telecommunication companies
Service providers for IT, network and telephone services
Involved bodies / organizations:
Service providers for web hosting, internet portals, online policy procurement, email marketing and live chat
Involved bodies / organizations:
Credit bureaus, address brokers
Collection of information during the application stage, claims management
Involved bodies / organizations:
Disposal of files and data media, document destruction
Involved bodies / organizations:
If required we will send you all contact details of our service providers.