Everything sounds very simple on the advice page of the Federal Ministry of Health: “Insured persons do not always have to accept the decisions of the health insurance company,” says Gesund.bund.de. “If your application for a benefit is rejected, you can appeal against it. In many cases, this is successful.” In many cases, however, not, as an investigation by the Federal Office for Social Security (BAS) has shown.
In its 2022 activity report, which was recently presented, the authority writes, Employees of the health insurance companies would be instructed to “motivate insured persons to withdraw their objection”. The insured persons are “often not fully informed” about the legal consequences of this withdrawal: Insured persons then no longer have the opportunity to take action against the decision of the health insurance fund. In addition, insured persons “were often given the impression by misleading letters” that the rejection of their objection had already been decided.
It’s about cures, rehabilitation measures and hearing aids
Above all, the BAS checked which work instructions the health insurers give their employees for processing contradictions. According to the report, “numerous legal problems” were identified again and again. A large part of the work instructions examined stipulates that the employees call insured persons, also several times, in order to dissuade them from their objection. The BAS warned eleven health insurance companies, including Barmer, Techniker Krankenkasse and several company health insurance companies. The Federal Office oversees around 60 statutory health insurance companies, which look after 45 million insured persons.
The Federal Commissioner for Patients’ Rights, Stefan Schwartze (SPD), spoke in the Picture-Newspaper of “Misinformation and Deception”. The fact that “unlawful action is taken on vital issues for patients cannot be tolerated in any way”. At the request of the Federal Ministry of Health Süddeutsche Zeitung with: “The fact that health insurance companies force insured persons to withdraw an objection to benefit notifications must not happen.”
A few years ago, the Berlin IGES Institute examines how many services the health insurance funds approve and reject. The study showed that a large part of the services requiring approval – applications for cures, rehabilitation measures or aids such as wheelchairs or hearing aids – are approved. The rejection rate was a good five percent. Patient organizations pointed out that older people, the severely disabled, the chronically ill and “educationally disadvantaged people” in particular were denied benefits. Year after year, more than 200,000 insured persons filed an appeal against a negative decision, the study explained.
The number would probably be significantly higher if the health insurance companies did not prevent the insured from objecting. However, the Federal Social Security Office cannot give a specific number of how often this actually happens. However, the office reports that efforts have been made to ensure that the health insurance companies concerned adapt their work instructions for objection procedures to the legal requirements. To this end, the BAS held talks with eleven health insurance companies and “was available to other health insurance companies in an advisory capacity to optimize their work instructions”, as stated in the 2022 activity report.
The coffers are now under more pressure. Does this help the insured?
The report comes as no surprise to the cash registers themselves. As early as June 2018, she informed the BAS in a letter that the provisions of the Social Security Code and the Social Court were “only insufficiently implemented in the processing of objections”. The letter explicitly spoke of practices that the current report also denounces. Insured persons are not obliged, when asked, to say whether they want to continue the procedure if the health insurance company does not meet them. Insured persons should also not “get the feeling” of being “pushed in a certain direction” when deciding on an objection. In August 2020, the cash registers received another letter from the authority with the same tenor.
In retrospect, however, most insured persons will not benefit from the fact that health insurance companies are now under more pressure. Even if the BAS found “that the carrier has urged an insured person to withdraw his objection, the administrative procedure at the carrier is initially complete,” explains the authority. Only in individual cases would insured persons have the opportunity “to submit a new application for benefits, which the institution must decide on again”.