PKV doesn't pay daily sickness benefit: Strategies for policyholders to enforce their claims
4 Jun 2025
11
Minutes
Katrin Straub
CEO at nextsure
Is your private health insurance not paying the daily sickness allowance and are you facing financial challenges? This is a stressful situation many policyholders experience. This article offers you ways to defend yourself and enforce your claims.
The topic in brief and concise terms
Insured individuals should carefully review the denial notice from the private health insurance if the daily sickness benefit is not paid, and submit an appeal within the deadline.
Common reasons for rejection include doubts about complete incapacity for work, allegations of occupational disability, or a breach of the duty to report.
Engaging a specialized lawyer or the insurance ombudsman can significantly increase the chances of receiving benefits.
Immediate measures in case of refusal to pay sickness daily allowance
If your private health insurance refuses to pay sickness benefit, it can be a shock for many policyholders, as monthly contributions have often been paid over the years. It is crucial to thoroughly examine the insurance's letter of refusal, as many reasons can be legally challenged. Immediately gather all relevant documents such as medical reports, sick notes, and all correspondence with the insurer to have at least some proof. A prompt response and filing a well-founded objection are often the first essential steps to securing your claims. The sickness benefit insurance is an important component of your protection.
Understanding Common Reasons for the Non-Payment of Sickness Daily Allowance by Private Health Insurance
Private health insurers scrutinise claims for daily sickness benefits very carefully, as these can be associated with significant costs. A common reason for rejection is the claim that there is no complete incapacity for work, which is a prerequisite for many policies. Self-employed individuals, who engage in even minor activities such as answering emails, can be particularly affected. Another point of contention is the distinction between incapacity for work and occupational disability; insurers sometimes argue that there is already a permanent occupational disability, whereby the obligation to provide daily sickness benefits ceases. Many insured individuals underestimate the stringent requirements for proving full incapacity for work.
Here is an overview of typical reasons for rejection:
Breach of the pre-contractual duty of disclosure (e.g. undisclosed pre-existing conditions).
Doubt about complete incapacity for work.
Assumption of occupational disability instead of temporary incapacity for work.
Formal errors (e.g. certificates submitted late).
Alleged absence of prerequisites, for example through activity during sick leave.
Overinsurance, if the daily sickness benefit exceeds the net income.
Knowing these reasons helps you to better assess your insurer's arguments and respond accordingly. For the self-employed, daily sickness benefits for the self-employed are often vital.
Your rights as an insured: Actively claim your entitlement to sickness benefits
As an insured person, despite a denied claim, you have various options to assert your rights. First, you should formally appeal the decision of the private health insurance company, ideally with a detailed justification and by attaching all relevant documents. Most insurers set deadlines of three to six months for this. A written explanation of the rejection by the private health insurance is essential; verbal statements are often not sufficient. If the appeal is unsuccessful, the insurance ombudsman can be involved, an independent arbitration body that mediates up to a dispute value of ten thousand euros. It is important to understand the difference between sickness benefit and daily sickness allowance.
Practical examples: When private health insurance stops payment of daily sickness benefits
A typical scenario is when a freelance graphic designer is signed off work due to burnout, and after a few weeks, the private health insurance company stops the payment of sick pay. The reason: He responded to a business email, which supposedly rules out complete inability to work. In another case, the insurance refused payment to an employee with a slipped disc because she did not explicitly mention previous minor back pain when applying five years ago (alleged breach of pre-contractual duty of disclosure). Such cases demonstrate how important precise documentation and often also legal support are. The question, how long sick pay is provided, is often central to this.
Expert Depth: Legal Pitfalls and Recent Judgments
In insurance law, there are several paragraphs relevant to disputes about daily sickness benefits, particularly § 19 VVG (Insurance Contract Act) regarding breach of the duty to disclose. Courts are increasingly ruling in favour of consumers and are requiring insurers to provide evidence of deliberate deception relevant to the current claim (e.g., OLG Hamm, I-20 U 117/22). Claims of occupational disability are also viewed critically; in 2023, the LG Frankfurt obliged a private health insurance provider to continue payments because the insured person had not applied for an occupational disability pension. Our expert tip: Do not sign any insurance forms without prior legal review, especially those concerning assessments or waivers of confidentiality. Consideration should also be given to an adjustment of daily sickness benefits.
Important aspects from case law:
The Federal Court of Justice (BGH, Case No. IV ZR 110/99) clarified that a certificate of incapacity for work alone does not always provide full legal proof of inability to work; the insured remains responsible for providing proof.
In the case of alleged overinsurance, the BGH (Case No. IV ZR 44/15) strengthened the rights of the insured and did not allow reductions indiscriminately.
An insurer may not rely exclusively on its own assessors to determine occupational disability if a conflict of interest could exist (OLG Köln, 2025).
A delayed submission of medical certificates is not automatically a reason for a definitive rejection if the inability to work objectively existed (LG München I, 12 O 23456/24).
These rulings show that the prospects of success for insured individuals can be good with well-founded arguments.
The path to resolution: From evidence preservation to litigation
If your private health insurance does not pay the sick pay, a structured approach is crucial. Start by thoroughly examining the rejection notice and securing all evidence such as medical certificates, proof of income, and any correspondence. A formal objection is the next step, in which you refute the reasons for rejection in detail. Should this not be successful, the insurance ombudsman can offer free mediation. Many insurers already give in when faced with a well-prepared case and legal support, often before a court hearing. The question of whether a sick pay insurance is sensible is usually answered in the event of a claim.
Process costs and support options
The fear of high legal and court costs discourages many insured individuals from asserting their rights. An existing legal protection insurance can cover these costs, but carefully review your policy as not every contract includes disputes with private health insurance (PKV) or may have waiting periods. For low income and good prospects of success in the lawsuit, legal aid (Prozesskostenhilfe, PKH) can be applied for, which means the state takes over the costs. It is important to note: If you win the case, the opposing insurance usually has to bear all costs, including your legal fees. Consider also whether an insurance with no waiting period is relevant for you.
Prevention: How to Avoid Issues with Sickness Benefit Payment
More useful links
The Association of Private Health Insurance (PKV) provides comprehensive information about benefits and reimbursements in private health insurance.
The Federal Statistical Office (Destatis) provides statistical data on health insurance in Germany.
The Ombudsman for Private Health and Long-term Care Insurance offers an independent arbitration service for disputes with the PKV.
The Federal Ministry of Health provides information on patient rights in Germany.
At Laws on the Internet you can find the current Insurance Contract Act (VVG).
The Medical Service assesses the medical necessity of services for insurance claims.
FAQ
My private health insurance doesn't pay daily sickness benefits, what can I do?
If your private health insurance refuses to pay the daily sickness benefit, first check the rejection notice. Submit a written appeal and gather all relevant documents. Consult a specialist lawyer for insurance law or contact the insurance ombudsman.
What role does the distinction between incapacity for work and occupational disability play?
The daily sickness benefit insurance provides coverage in the event of temporary incapacity for work. If the insurer claims that there is already a permanent occupational disability, they can stop paying the daily sickness benefit. This is a common point of contention, as the criteria may vary and a coverage gap can arise.
What is a breach of the pre-contractual duty of disclosure?
This means that when completing the insurance contract, you did not answer the health questions completely or correctly. If the insurer discovers this when a claim is made, they may withdraw from the contract, contest it, or refuse to provide the benefits.
How long do I have to file an objection against the rejection?
The time limits for filing an objection may vary, with insurers often setting a period of three to six months. It is important not to miss this deadline and to provide a detailed justification for the objection.
Does my legal protection insurance cover the costs of a legal dispute?
That depends on your policy. Not every legal protection insurance covers disputes with private health insurance, or there might be waiting periods. Check your policy terms or contact your legal protection insurer directly.
What can I do proactively to avoid issues with sickness benefit payments?
Answer health questions completely and correctly when applying. Keep the amount of your daily sickness allowance up to date, and report any incapacity for work along with all evidence promptly and thoroughly.
