Can my health insurer refuse a treatment?

Your health insurer may refuse a treatment if it is not covered by the basic package or is not considered effective according to medical standards. This happens more often than you think, but there are rules that insurers must follow. It is important to know when a refusal is justified and what steps you can take.

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The short answer

Health insurers may refuse treatments, but only under specific circumstances. The treatment must be included in the basic package and be medically necessary. The treatment must also be effective according to current medical standards. A refusal must always be substantiated in writing. As a patient, you have the right to object to this decision.

What does the law say?

The Health Insurance Act regulates when an insurer may refuse a treatment. Insurers must reimburse all care in the basic package, but only if it is medically necessary. The treatment must also meet the current state of science and practice. Requesting a second opinion can help in case of doubt about the necessity.

1Health Insurance Act Article 11: basic package must be reimbursed

2Medical Treatment Contracts Act: right to careful treatment

3Awb (General Administrative Law Act): right to a reasoned decision and objection

What should you pay attention to?

Pay close attention to the reasoning of your insurer when a refusal is made. Always request a written explanation if you have not yet received one. Check whether the treatment is actually included in the basic package on your insurer's website. Keep all correspondence and medical documents relevant to your case.

1Always request a written explanation of the refusal

2Check if the treatment is included in the basic package

3Keep all medical documents and correspondence

4Pay attention to objection deadlines (usually 6 weeks after the decision)

Example from practice

Maria is told that she needs physiotherapy after an operation. Her health insurer refuses this because she has already had 20 physiotherapy sessions this year, while the basic package only covers 20 sessions. Maria asks her specialist for a medical justification why additional sessions are necessary. With this justification, the insurer agrees after all, because the treatment is medically necessary due to complications after the operation.

What can you do?

Contact your treating physician for additional medical justification. File a formal objection with your health insurer within 6 weeks. If that doesn't help, you can go to the Kifid (complaints institute) for mediation.

1Ask your doctor for additional medical justification for the necessity

2File a substantiated objection with your insurer within 6 weeks

3Go to the Kifid if the objection is rejected

Conclusion

A health insurer cannot simply refuse any treatment, but must comply with clear rules. If you disagree with a refusal, you can always file an objection. Make sure you document all the steps properly and adhere to the objection deadlines.

Frequently Asked Questions

What should I do if my insurer does not provide a written explanation?

Can I go directly to court if my treatment is refused?

Can an insurer refuse a treatment because it is too expensive?

What happens if I want a second opinion but my insurer refuses?

Do I have to pay for the treatment myself during an objection procedure?

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