Is there really a supplementary dental insurance with a performance guarantee?
29 May 2025
Katrin Straub
Managing Director at nextsure
A large dentist bill is coming, but the insurance does not cover the full amount. Many insured individuals fear this scenario. We clarify what a 'performance guarantee' really means and how you can safely avoid pitfalls in contracts.
The topic in brief and concise terms
There is no 'performance guarantee' in the literal sense; the obligation of the dental supplementary insurance always depends on the detailed contractual terms.
Key factors for cost coverage are clauses on medical necessity, the fee schedule (GOZ), and benefit limitations in the initial years (dental scale).
The submission and approval of a treatment and cost plan (HKP) before the start of treatment is the most important step to receive a binding commitment from the insurer.
Die Angst vor hohen Zuzahlungen beim Zahnarzt ist weit verbreitet, denn Zahnersatz kann schnell mehrere tausend Euro kosten. Eine Zahnzusatzversicherung verspricht Abhilfe und wirbt oft mit einer Kostenübernahme von bis zu hundert Prozent. Doch was passiert, wenn die Versicherung die Leistung kürzt oder ganz verweigert? Der Begriff „Leistungsgarantie“ suggeriert eine hundertprozentige Sicherheit, die es in der Praxis so nicht gibt. Dieser Artikel erklärt, warum die tatsächliche Leistung von den Details im Versicherungsvertrag abhängt, wie Sie diese Details verstehen und wie Sie mit einem Heil- und Kostenplan Ihre Ansprüche wirksam absichern.
The Promise of Performance Guarantee: A Close Look at Reality
Many insurance plans advertise covering 90 or even 100 percent of costs, which is understood as a type of performance guarantee. In reality, however, this promise is subject to numerous conditions detailed in the fine print of the contract. There is no genuine, unconditional guarantee; the obligation to perform is determined by the Insurance Contract Act (VVG) and the specific tariff details. For instance, if a dentist bills a treatment for 2,000 euros, the insurer may reduce the coverage to 1,500 euros if they question the medical necessity of certain items. The promised 90 percent would then only apply to this reduced amount. Thus, what was hoped to be security can quickly become a financial disappointment, even though the costs for dental prostheses can be significant. The decisive factors for cost coverage are not the promotional promises, but the specific contract conditions.
Contract Pitfalls: These Clauses Limit Your Cost Reimbursement
Insured individuals often receive full benefits only after several years, which many overlook when signing up. To achieve the advertised high reimbursement, several hurdles in the contract need to be overcome. Particularly, the definition of medical necessity is a frequent point of contention. Here is a list of the key clauses you should be aware of:
Medical necessity: Insurers only cover treatments they deem medically necessary, a definition they often set themselves.
Fee schedule (GOZ): Dentists can charge up to 3.5 times the fee schedule for dentists (GOZ) for private services; your plan must cover these rate increases.
Price and service index: Some insurers have their own lists of "reasonable" prices for materials and laboratory work, which are often below the actual costs.
Dental scale: In the first three to five years, the benefits are limited to maximum amounts, for example, up to 1,000 euros in the first year.
Waiting periods: For many treatments, especially dental prosthetics, there is a waiting period of up to eight months during which no benefits are provided.
Understanding these points clearly is crucial in knowing when insurance does not pay out. These clauses significantly influence how much your own contribution truly amounts to in the end.
The Treatment and Cost Plan: Your Tool for Maximum Cost Security
The most important step to secure your claims is the submission of a treatment and cost plan (HKP) before the start of treatment. This document is a detailed cost estimate from your dentist, listing the diagnosis, planned therapy, and expected costs. The insurer's written approval of the HKP is the most binding form of commitment to benefits that you can receive. This approval is usually valid for six months and binds the insurance to the promised benefits. If the final invoice deviates from the plan by more than 15 percent, the dentist must inform you. A comparison of dental supplementary insurances shows that the handling of HKPs is an important quality feature. However, even with a commitment, discussions may arise if the insurance subsequently reduces individual items.
Benefits reduced: How to successfully defend against the insurance company
If your supplementary dental insurance refuses or reduces payment, you don't simply have to accept it. There is a clear process through which you can assert your rights. Thousands of disputes are decided in favour of the insured each year. Here are the four crucial steps:
Submit a written objection: Request a detailed and written explanation of the reduction from the insurer, and formally submit an objection.
Seek a second opinion: An assessment from a second dentist can substantiate the medical necessity of the treatment and strengthen your position.
Engage the PKV ombudsman: The ombudsman of private health insurance offers a free and out-of-court conciliation procedure, which is binding for insurers up to a dispute value of €10,000.
Consult a specialist lawyer for insurance law: As a last resort, a lawyer can help enforce your claims in court, which is especially sensible for large amounts.
The right approach can make the difference between bearing high costs or receiving the benefits you are entitled to. Choosing the right supplementary dental insurance is the best prevention.
More useful links
The Consumer Advice Centre discusses the risks and benefits of dental supplementary insurance from their perspective.
The Association of Private Health Insurance (PKV) reports on the strong growth of dental supplementary insurance in Germany.
Statista provides statistical data on the expenditures of statutory health insurance (GKV) for dental prostheses since 2004.
The GKV Central Association provides key figures and general information about statutory health insurance.
Statista compares the benefits of private and statutory health insurance for dental treatment and prosthetics.
The National Association of Statutory Health Insurance Dentists (KZBV) offers comprehensive information about dental care in Germany.
The Berlin Association of Statutory Health Insurance Dentists (KZVB) informs patients about supplementary insurance.
FAQ
Gibt es eine Zahnzusatzversicherung, die alles zahlt?
Nein, eine Zahnzusatzversicherung, die bedingungslos alles zahlt, gibt es nicht. Jeder Tarif hat Bedingungen, Ausschlüsse und Begrenzungen. Premium-Tarife bieten zwar eine sehr hohe Kostenübernahme, doch auch hier müssen die vertraglichen Voraussetzungen wie die medizinische Notwendigkeit erfüllt sein.
Worauf muss ich bei den Versicherungsbedingungen besonders achten?
Achten Sie vor allem auf die Höhe der Erstattung für Zahnersatz, die abgedeckten Sätze der Gebührenordnung für Zahnärzte (bis 3,5-fach empfohlen), die Regelungen zur professionellen Zahnreinigung und ob der Tarif auf ein eigenes Preis-Leistungsverzeichnis für Laborkosten verzichtet.
Ist eine Zahnzusatzversicherung ohne Wartezeit immer besser?
Eine Versicherung ohne Wartezeit bietet sofortigen Schutz, was ein großer Vorteil ist. Aber Achtung: Behandlungen, die vor Vertragsabschluss bereits angeraten oder geplant waren, sind in der Regel trotzdem ausgeschlossen. Prüfen Sie daher immer die genauen Bedingungen.
Was ist eine Zahnstaffel?
Die Zahnstaffel ist eine Leistungsbegrenzung in den ersten Versicherungsjahren. Der Versicherer erstattet beispielsweise im ersten Jahr maximal 1.000 Euro, im zweiten 2.000 Euro usw. Erst nach Ablauf dieser Staffelung (meist nach drei bis fünf Jahren) steht die volle vertragliche Leistung zur Verfügung.
Übernimmt die Versicherung auch Kosten für Behandlungen im Ausland?
Das hängt vom Tarif ab. Viele gute Tarife leisten auch für Behandlungen innerhalb der EU zu den gleichen Konditionen wie in Deutschland. Bei Behandlungen außerhalb der EU gibt es oft Einschränkungen oder niedrigere Erstattungssätze. Dies muss vorab geprüft werden.
Was passiert, wenn mein Zahnarzt teurer abrechnet als die Versicherung erlaubt?
Wenn Ihr Zahnarzt einen höheren Satz der Gebührenordnung (GOZ) abrechnet, als Ihr Tarif abdeckt (z.B. über dem 3,5-fachen Satz), müssen Sie die Differenz selbst tragen. Deshalb ist es wichtig, einen Tarif zu wählen, der hohe GOZ-Sätze erstattet und dies vor einer teuren Behandlung zu klären.
