A protracted corona disease in the spring, then a complicated fracture a few months – such a medical history is really not to be desired by anyone. At least the financial aspects are taken care of in Germany: Employees initially receive continued wages from their employer for six weeks. Anyone who is ill for a longer period of time and is insured in the statutory health insurance scheme (GKV) will then receive sick pay from the health insurance company.
Privately insured persons can take out daily sickness allowance insurance for the time after the continued payment of wages. In the event of a prolonged illness, however, they are at risk of unexpected financial losses if they have already received daily sickness benefit within the past twelve months. The analysis company Premium Circle warns of this in a recent study by the Süddeutsche Zeitung present. The problem: vague contractual clauses offer insurers the opportunity to reduce payments in the event of repeated incapacity to work. It is difficult to say whether this will happen and how severe the cut will be. “That’s an Achilles’ heel,” complains Hendrik Scherer, Managing Director of Premium Circle. “There is an urgent need to create security for customers.”
During the pandemic, in which several longer periods of incapacity to work within twelve months are more common than usual, Premium Circle became increasingly aware of privately insured people who complained about such cuts in benefits. The company then took a closer look at the contract terms of 28 private health insurers (PKV) with a combined market share of more than 99 percent.
Those who have received income replacement may receive less sick pay
The sticking point is a paragraph in the model conditions. This stipulates that a daily sickness allowance policy can be used to insure the net income from professional activity over the past twelve months. “But what counts as net income from professional activity and what doesn’t is not defined in more detail,” explains Scherer. This means that if a customer received daily sick pay from his insurer for three months in the spring, for example, these amounts do not count if the insurer evaluates them as income replacement and not as net income. The insurer can therefore reduce the daily sickness allowance that the customer now receives because of his second inability to work by only using the professional income from the remaining nine of the past twelve months to calculate the amount. The same applies to other forms of income replacement, such as short-time work benefits. Any further incapacity to work during which the insured person receives sick pay or short-time work benefits can reduce the payment.
This does not only apply to private patients. Many people with statutory health insurance have taken out private daily sickness allowance insurance as an additional policy in order to top up the benefits of the health insurance company. The sick pay that the health insurance company pays after the employer has continued to pay wages for six weeks is limited: it is 70 percent of gross earnings, but no more than 90 percent of net – minus social security contributions. So if you earn 3000 euros gross and get paid almost 2000 euros net, you will receive less than 1600 euros sick pay.
At first glance, it doesn’t seem to be as bad for those with statutory insurance as it does for those with private insurance if the private health insurance company cuts the daily sickness allowance – after all, they still get money from the health insurance company. However, the legislature has limited sick pay to a total of 3386 euros gross per month, after social security deductions a maximum of 2979 euros remain. This means that the further your own net salary is above the maximum amount, the greater the income gap if the supplementary insurance does not pay in full.
The good news: “About half of the insurers don’t stick to their own clauses to the benefit of their customers,” says Premium Circle Managing Director Scherer. The company’s inquiries to insurers have revealed that some providers extrapolate the income from the months in which the customer actually worked to twelve months. Nevertheless: “Even if some insurers handle it in practice in such a way that there is no loss, the insured ultimately have no legal claim to this goodwill,” says Alexander Schäfer, specialist lawyer for insurance and medical law. Insurers could invoke their clauses at any time and reduce benefits.
“Hoping in the self-healing powers of the insurance industry has never really worked.”
After a ruling by the Federal Court of Justice (BGH) in 2016, private health insurers were once asked to revise their clauses, which the BGH judges had regarded as too opaque. “The insurers have tried to regulate this again, but the clauses ultimately got worse,” says Schäfer. In order to create clarity for the benefit of all customers, a new customer lawsuit would be needed against an insurer, which then also ends up before the BGH, explains the lawyer. However, he is not optimistic that this will happen. Proceedings up to the BGH require staying power. It is also conceivable that a defendant insurer would give in beforehand and thus prevent the case from even going to this instance. “The situation would only change if there were suddenly a large number of procedures,” says Schäfer.
The private health insurance association sees no need for action. “The private health insurance association only provides non-binding sample conditions for insurance companies that operate daily sickness allowance insurance,” explains a spokesman. How the term “net income” is dealt with has nothing to do with the model conditions, but with the individual company tariff conditions. “We can therefore not comment on the interpretation of these insurance conditions of the individual daily sickness benefit insurance.”
In the opinion of attorney Schäfer, the legislature should solve the problem. He thinks it is unlikely that insurers will change their clauses without external pressure. “Hoping in the self-healing powers of the insurance industry has never really worked.”