Health insurance estimate: Guide & tips

A cost estimate submitted to the health insurer is often the first step towards important medical benefits. Many insured people are unsure how to proceed, which deadlines apply, or what to do if a request is rejected. This article guides you safely through the process.

Understanding a cost estimate: The basis for your benefit approval

A quotation is a commercial preliminary calculation. It gives you and your health insurance provider a detailed overview of the expected costs of a medical treatment or a medical aid. For you as a patient, the quotation is usually non-binding. Only once you have signed it and it has been approved by the health insurer does it become the basis for the provision of services. Many treatments, particularly for medical aids, absolutely require a quotation approved in advance. This requirement often arises from the supply contracts between health insurers and service providers. Without this approval, you risk being left to cover the costs yourself. The exact rules may vary depending on the health insurer and the type of service. It is therefore important to understand the process precisely.

The path to an approved estimate: a step-by-step guide

The process for approving a cost estimate, especially for assistive devices, usually follows a clear pattern. It often begins with a medical prescription confirming the medical necessity. With this prescription, you contact an authorised provider, for example an orthopaedic supply store or an audiology specialist. After selecting the appropriate assistive device, this provider prepares the cost estimate. This is then submitted to your health insurance fund – often directly by the provider. Since 1 February 2023, electronic submission has been mandatory for assistive devices. This speeds up the process and saves administrative costs.

For certain assistive devices such as visual aids or hearing aids, there are fixed reimbursement amounts that cap the maximum cost coverage by statutory health insurance. Your co-payment is legally ten per cent of the costs, but at least five euros and at most ten euros. For consumable assistive devices, it is ten per cent per pack, but no more than ten euros per month. Careful review of all documents before submission can significantly increase the chances of success. Also find out about supplementary insurance for dental prosthetics, as cost estimates are often required here.

Deadlines at a glance: What policyholders need to know

Health insurance funds must process benefit applications promptly. The Social Code sets out clear deadlines here. In principle, your health insurance fund must have decided on your application no later than three weeks after receipt. This deadline is regulated in Section 13(3a) of SGB V. If an assessment by the Medical Service (MD) is required, the deadline is extended to five weeks. The health insurance fund is obliged to inform you of the need for an assessment. For dental treatments requiring an assessment, the deadline is six weeks. If the health insurance fund cannot meet these deadlines, it must inform you in writing or electronically in good time and state the reasons. Our expert tip: always send important applications by registered mail with proof of delivery so that you can evidence receipt. Knowledge of deadlines is also relevant with private health insurance, although the exact rules may differ.

If the health insurance fund does not provide sufficient justification for a delay, there is an important rule: once the deadline has expired, the benefit is deemed to have been approved. If you then obtain the required benefit yourself, the health insurance fund is obliged to reimburse the costs incurred. This underlines the importance of documenting deadlines precisely and following up when they are exceeded.

Rejecting a quote: How to defend yourself successfully

Rejecting the cost estimate is frustrating, but no reason to resign yourself to it. You have the right to lodge an appeal. You have one month to appeal after receiving the rejection notice. The appeal must be made in writing and should ideally be sent to your health insurance provider by registered post. It is advisable to carefully review the health insurance provider’s reasoning and substantiate your appeal thoroughly. Enclose medical statements or other relevant documents that demonstrate the necessity of the service. The health insurance provider then has three months to decide on your appeal. If the appeal is also rejected, you may take the matter to the Social Court; the time limit for this is again one month. Many appeals are successful, so this step is often worthwhile. You can find support, for example, from social welfare organisations or specialist lawyers. An appeal may also be necessary for services such as psychotherapy with a non-medical practitioner.

Here are the steps for an appeal:

• Review the rejection notice and the information on legal remedies carefully.
• Submit your appeal in writing within one month.
• Explain in detail why the service is medically necessary.
• Enclose supporting documents (e.g. medical reports).
• Send the appeal to the health insurance provider in a verifiable way (e.g. by registered post).
• If it is rejected again, you can file a claim with the Social Court.

Cost reimbursement: An alternative to direct billing

People insured under statutory health insurance can choose reimbursement of costs instead of the usual benefits in kind or services. This means that you initially pay for the service yourself and then submit it to your health insurer for reimbursement. However, the entitlement to reimbursement is limited to the amount the insurer would have covered under a benefit in kind. In addition, the health insurer may deduct administration costs of up to five per cent. The choice of reimbursement should be carefully considered and binds you for at least one calendar quarter. This may be relevant, for example, for benefits such as a new pair of glasses covered by statutory health insurance. Always clarify the details with your health insurer in advance. Some insurers also offer special reimbursement tariffs, which may allow higher reimbursements, but these cost an additional premium and have a binding period of at least one year.

Special case: private health insurance (PKV) — this applies to cost estimates

In private health insurance (PKV), submitting cost estimates, especially for more expensive treatments, is often a contractual prerequisite for reimbursement. From an estimated invoice amount of two thousand euros, policyholders have a statutory right to a binding statement on reimbursement eligibility. For those entitled to state aid, this applies from as little as one thousand euros. The PKV must provide this information within four weeks, or within two weeks at the latest in urgent cases. If this deadline is missed, the treatment is deemed medically necessary, which makes enforcing claims easier, even though reimbursement still takes place in accordance with the tariff. Submitting a cost estimate can speed up the process and gives you financial certainty before treatment begins. This is particularly important for planned procedures or high-quality dental prostheses. Also consider a hospital supplementary insurance policy to cover optional services.

Expert tips for a smooth process

To make the process around the estimate as smooth as possible, there are a few tried-and-tested tips. Our expert tip: Check with your health insurance provider in advance whether an estimate is required for the planned service and which documents are needed exactly. A correct and complete medical prescription is often the key to success. Make sure that the diagnosis, quantity and type of service are specified exactly. For aids, the aid number and product type should be stated. A precise description of what the aid is needed for is also helpful. Document all steps and keep copies of all submitted documents and correspondence with the health insurance provider carefully. This is particularly important in case of queries or an appeal process. If anything is unclear, a hearing aid insurance policy can provide additional security.

Checklist for submission:

• Obtain medical prescription (prescription).
• Choose a service provider approved by the health insurance fund.
• Have a suitable aid/treatment selected.
• Have a detailed estimate prepared.
• Submit the estimate (if applicable with the prescription) to the health insurance provider (electronically for aids).
• Wait for written confirmation of cost coverage.
• Observe the deadlines for the insurer's decision.
• If refused, lodge an objection within the deadline.

Conclusion and your next step towards optimal cover

The cost estimate is an important tool for gaining clarity about medical costs and ensuring that your health insurance covers the services. With knowledge of processes, deadlines and your rights, you can actively help to ensure that your application is successful. Good preparation and accurate documentation are crucial here. Do not underestimate the possibility of lodging an objection if an application is refused – this often leads to success. Bear in mind that, alongside statutory cover, private supplementary insurance, such as a dental supplementary insurance or a glasses insurance, can also close gaps in provision. Comprehensive advice helps you meet your individual needs and be optimally covered. Take the opportunity to receive independent advice.