Is there really a dental insurance with a performance guarantee?
29 May 2025
11
Minutes
Katrin Straub
CEO at nextsure
A high dental bill is coming, but the insurance doesn't cover the full amount. Many policyholders 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 to perform under the dental supplementary insurance always depends on the detailed contractual terms.
Critical for the cost coverage are clauses on medical necessity, the fee schedule (GOZ), and limitations on benefits in the first few years (dental scale).
Submitting and approving a treatment and cost plan (HKP) before starting treatment is the most important step to obtain a binding commitment from the insurer.
The Promise of Performance Guarantee: A Closer Look at Reality
Many plans advertise covering costs up to 90 or even 100 percent, which is understood as a form of performance guarantee. However, in reality, this promise is tied to numerous conditions listed in the fine print of the contract. There is no true, unconditional guarantee; the obligation to perform is based on the Insurance Contract Act (VVG) and the specific tariff details. For example, if a dentist bills 2,000 euros for a treatment, the insurance can 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. This quickly turns a hoped-for security into financial disappointment, even though the costs for dental prostheses can be significant. The decisive factors for cost coverage are not advertising promises but the specific contract conditions.
Contract Pitfalls: These Clauses Limit Your Cost Reimbursement
Insured individuals often receive the 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 rate of the fee schedule for dentists (GOZ) for private services; your tariff must cover these increased rates.
Price and Service List: Some insurers have their own lists of 'reasonable' prices for materials and laboratory work, which often fall below the actual costs.
Dental Scales: In the first three to five years, benefits are limited to maximum amounts, for instance, up to 1,000 euros in the first year.
Waiting Times: For many treatments, especially dentures, there is a waiting period of up to eight months, during which no benefits are provided.
A thorough understanding of these points is crucial to knowing when an insurance does not pay out. These clauses significantly determine how high your personal contribution ultimately turns out to be.
The Treatment and Cost Plan: Your Tool for Maximum Cost Security
The most important step to securing your claims is the submission of a treatment and cost plan (HKP) before treatment begins. This document is a detailed cost estimate from your dentist, listing the diagnosis, the planned therapy, and the expected costs. The written approval from the insurer for the HKP is the most binding form of commitment you can receive. This approval is usually valid for six months and binds the insurance to the promised services. If the final invoice deviates by more than 15 percent from the plan, the dentist must inform you. A comparison of dental insurance shows that the handling of HKPs is an important quality feature. However, even with an approval, discussions can arise if the insurer subsequently reduces certain items.
Benefit reduced: How to successfully stand up to the insurance company
If your dental supplementary insurance refuses or reduces payment, you do not have to simply accept this. There is a clear process through which you can assert your rights. Every year, thousands of disputes are decided in favour of the insured. Here are the four crucial steps:
Submit a written objection: Request a detailed written explanation from the insurer for the reduction and formally lodge an objection.
Get a second opinion: An assessment from a second dentist can substantiate the medical necessity of the treatment and strengthen your position.
Involve the PKV Ombudsman: The Ombudsman for private health insurance offers a free and out-of-court arbitration procedure, which is binding for insurers up to a dispute value of 10,000 euros.
Consult a specialist lawyer for insurance law: As a last resort, a lawyer can help enforce your claims in court, which is especially meaningful for large amounts.
The right approach can make the difference between being left with high costs or receiving the benefits to which you are entitled. Choosing the appropriate dental supplementary insurance is the best prevention in this case.
Expert Tips: How to Find a Plan with Genuine Performance Assurance
To avoid the situation of a refusal to provide benefits in the first place, selecting the right plan is crucial. Our expert tip: Specifically look for rates that waive their own price and performance directory for laboratory costs. These rates accept the local prices and significantly reduce the risk of deductions. Also, make sure that the dental fee schedule (GOZ) is covered up to at least 3.5 times, as this is often necessary for complex treatments. A good plan may cost around 40 to 50 Euros per month, but it will protect you from co-payments of several thousand Euros in an emergency. Transparent conditions are more important here than the promise of a hundred percent reimbursement. With these criteria in mind, you can find the best dental supplementary insurance and secure yourself in the long term.
Request an individual risk analysis now: Have your insurance situation checked free of charge and receive specific optimization suggestions.
More useful links
The Consumer Advice Centre discusses the risks and benefits of dental insurance from their perspective.
The Association of Private Health Insurance (PKV) reports on the strong increase in dental insurance policies in Germany.
Statista provides statistical data on the expenditures of statutory health insurance (GKV) for dental prosthetics since 2004.
The GKV Central Association provides key figures and general information on statutory health insurance.
Statista compares the services of private and statutory health insurance for dental treatment and prosthetics.
The National Association of Statutory Health Insurance Dentists (KZBV) offers comprehensive information on dental care in Germany.
The Berlin Association of Statutory Health Insurance Dentists (KZVB) informs patients about supplementary insurance.
FAQ
Is there a supplementary dental insurance that covers everything?
No, there is no dental supplementary insurance that pays for everything unconditionally. Every plan has conditions, exclusions, and limitations. Although premium plans offer a very high cost coverage, the contractual requirements such as medical necessity must also be met here.
What should I particularly pay attention to in the insurance terms and conditions?
Pay particular attention to the level of reimbursement for dental prostheses, the covered rates of the fee schedule for dentists (up to 3.5 times recommended), the provisions for professional teeth cleaning, and whether the tariff dispenses with its own price-performance directory for laboratory costs.
Is a supplemental dental insurance without a waiting period always better?
An insurance policy without a waiting period offers immediate coverage, which is a significant advantage. However, be aware that treatments advised or planned before the contract was signed are typically still excluded. Therefore, always check the exact terms and conditions.
What is a dental scale?
The 'Zahnstaffel' is a limit on benefits during the initial years of the insurance. For example, the insurer may reimburse a maximum of €1,000 in the first year, €2,000 in the second year, and so on. Only after this graduation period (typically after three to five years) is the full contractual benefit available.
Does the insurance also cover costs for treatments abroad?
That depends on the tariff. Many good tariffs also cover treatments within the EU under the same conditions as in Germany. For treatments outside the EU, there are often restrictions or lower reimbursement rates. This needs to be checked in advance.
What happens if my dentist charges more than the insurance allows?
If your dentist charges a higher rate according to the fee schedule (GOZ) than your tariff covers (e.g., above the 3.5 times rate), you will have to bear the difference yourself. Therefore, it's important to choose a tariff that covers high GOZ rates and to clarify this before undergoing an expensive treatment.
