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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 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 and Provisit Student in combination with benefit level 1: Deductible = €0

Provisit Student in combination with benefit level 2: Deductible = €300

As of 01 January 2023

Benefits overview

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.

Insurability

Eligible for insurance

• are persons traveling to Germany with a residence permit for Germany limited to a maximum of five years

and

• their accompanying spouses, domestic partners and children, if they also have a temporary residence permit for Germany.

1. Benefits

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),
• ophthalmologists,
• gynecologists,
• pediatricians,
• 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 clause 2.1).

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.

d) Remedies

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 Bundesministerium des Innern und für Heimat; 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).
• Supportive care services. Supportive care includes benefits from basic home care and household assistance, as long as there is no need of care with care level 2 to 5 for the insured person. Supportive care may be prescribed for a period of up to 4 weeks per case of illness due to serious illness or acute aggravation of an illness, especially after hospitalization due to illness or accident or after outpatient surgery.

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.

h) Fertility treatment and cryopreservation

Expenses for assisted reproduction measures (insemination, in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), hormonal stimulation with drugs) are refundable if the following conditions are met:

• There is an organically caused infertility of the insured person, which can be overcome exclusively by means of reproductive medical measures, as listed in the corresponding medical report,
• the treatment is carried out in the homologous system in a couple that is married or living in cohabitation and
• there is a sufficient chance of success of at least 15%.

Fertility treatment is very cost-intensive. We therefore recommend that you clarify your right to benefits before starting treatment. We will then be happy to clarify for you which benefits you can expect.

Expenses for cryopreservation and storage of egg and sperm cells as well as for the associated measures are also refundable if, for example, the ability to conceive is endangered by chemotherapy or radiotherapy in the case of cancer (even without direct fertility treatment).

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

Refundable are

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

and

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.

1.10 Transitional hospital care

Refundable expenses are those for transitional hospital care for a maximum period of 10 days, per hospital treatment.

The prerequisite is that

• the transitional hospital care immediately follows completed hospital treatment
• it is provided in the hospital in which the hospital treatment also took place
• no benefits of home nursing care, short-term care, medical rehabilitation or nursing benefits according to book 11 of the German Social Code (SGB XI) can be provided or can only be provided at considerable expense.

The costs are covered regardless of an existing need of care according to SGB XI.

Reimbursement is 100% of refundable expenses.

1.11 Digital health applications

Refundable expenses include the cost of using digital health applications.

Digital health applications are medical products whose main function is essentially based on digital technologies. These products are intended to aid in the detection, monitoring, treatment or mitigation of disease or the detection, treatment, mitigation or compensation for injury or disability.

The prerequisite is that the digital health application

is prescribed by a licensed physician, licensed dentist, licensed psychotherapist or child and adolescent psychotherapist, or non-medical practitioner or

is approved by the insurer on the basis of a proven medical indication.

The insurer will not reimburse the cost of using the digital health applications. This includes, for example, the acquisition costs for the smartphone or the maintenance costs such as electricity or batteries.

Reimbursement is 100% of refundable expenses.

1.12 Deductibles

An annual deductible shall be deducted from the tariff benefits under clauses 1.1 to 1.11. 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 january 2024

INSURANCE COVERAGE

§ 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.

§ 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.

§ 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

a) accidents;

b) the spouse or civil partner (the term „civil partner“ refers to „life partners“ pursuant to Section 1 of the German Civil Partnership Act in the version valid until 22 December 2018) 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.

§ 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.

§ 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, 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.

§ 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. The prohibition of assignment according to sentence 1 applies not for contracts concluded after October 1, 2021; Statutory prohibitions of assignment remain unaffected.

(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.

§ 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

§ 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.

§ 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.

§ 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) cancelled

(4) cancelled

(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.

§ 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.

§ 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.

§ 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.

§ 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.

§ 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.

§ 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.

OTHER PROVISIONS

§ 16 Declarations of intent and notifications

Declarations of intent and notifications to the insurer must be made in writing.

§ 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).

§ 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.

§ 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.

References to the consumer arbitration board ombudsman for private health and long-term care insurance, Insurance supervision and legal recourse

Reference to the consumer arbitration board ombudsman for private health and long-term care insurance

Policyholders who are not satisfied with the insurer’s decisions or their negotiations with the Insurers that have not achieved the desired result can contact the Ombudsman for Private health and long-term care insurance.

Ombudsmann für private Kranken- und Pflegeversicherungen (ombudsman for private health and long-term care insurance)
Postfach 060222
10052 Berlin

Internet: www.pkv-ombudsmann.de

The ombudsman for private health and long-term care insurance is an independent Arbitration Board that works free of charge for consumers. The insurer has undertaken to take part in the arbitration procedure.

Consumers who have concluded their contract online (e.g. via a website) can also submit their complaint online via the platform http://ec.europa.eu/consumers/odr/. Your complaint will then be sent to the ombudsman for private health and long-term care insurance.

Note: The ombudsman for private health and long-term care insurance is not an arbitration body and cannot deal with individual disputes
make a binding decision.

Reference to the insurance supervision

If policyholders are not satisfied with the care provided by the insurer or if there are disagreements in the execution of the contract they can also contact the supervisory authority responsible for the insurer. The Insurance companie is subject to the supervision of the Federal Financial Supervisory Authority.

Bundesanstalt für Finanzdienstleistungsaufsicht (Federal Financial Supervisory Authority)
Graurheindorfer Straße 108
53117 Bonn

E-mail: poststelle@bafin.de

Note: BaFin is not an arbitration board and cannot make binding decisions on individual disputes.

Reference to the legal process

Regardless of the possibility of contacting the consumer arbitration board or the insurance supervisory authority, the Policyholder has the right to legal recourse.