Question of the week: Who helps if the insurance does not pay?-
Although consumers with private health insurance (PHI) are often well protected in the event of illness, they sometimes have to fight for their benefits. According to a report by the so-called PKV Ombudsman, the dispute over fees or the reimbursement of medical treatment and hospital stays are the most frequent complaints of private insured persons.
In 2016, some 6,000 problem reports were received by around 8.8 million private insured persons from the neutral and independent intermediary in private health insurance , who should settle the matter in case of dispute. Compared to the previous year, this is an increase of 5.44 percent.
What options are available if the insurance does not pay?
As a rule, insurers respond promptly to a claim. If the provider remains silent, customers should check and at the same time set a time limit for the refund or payment. If the insurer directly refuses the service, it is advisable to look closely at the contract documents. There may be exclusions agreed that are now. If the insurer does not pay, although there are no exceptions in the contract, customers can object to the decision of the company. For correspondence with the company, they should always collect evidence, for example, send the objection by registered letter and return receipt.
In the case of a dispute with the insurance company, the motto is basically: to remain persistent and not to let go . This is true, for example, if the insurer should try to hold the person responsible responsible for the damage. Some companies also offer customers a comparison, where reimbursement is usually lower, but long disputes are spared. Before they agree, they should weigh up if that’s enough. Because then they have no further benefit claim for the damage.
Who helps insured people with their insurance?
If the insurer does not respond or refuses to pay for the damage, insured persons may first refer their concerns to the company’s complaints department. They also have the option of contacting the so-called Insurance Ombudsman. This independent intermediary reviews your request and decides what to do next. Up to a damage amount of 10,000 euros, the decisions of the Ombudsman are binding, after which they are considered recommendations.
Another point of contact is the various consumer centers in the federal states. These offer a telephone consultation and take over the out-of-court representation of consumers . However, in contrast to the complaint to the Ombudsman, the offer is subject to a fee.
Ombudsmen for different concerns
In addition to the Insurance Ombudsman and the PKV Ombudsman, there are other ombudsmen in Germany. For example, consumers can contact various arbitration boards in case of problems with banks, building societies or credit and real estate matters.
Litigation as a last resort for insurance problems
Anyone looking for help from the German Federal Financial Supervisory Authority should know that they are only concerned about basic problems . It acts, among other things, when a company changes its terms and conditions without informing the customers.
Insured persons can also take legal action if the insurance company does not pay. For this they should get the best support from a lawyer. In the event of a dispute, legal expenses insurance generally covers the court and attorney’s fees. Depending on the amount of damage, those affected should consider carefully whether the cost of a legal dispute is worthwhile for them.
How can insurance policy be avoided?
Often there is a reason for it, if the insurance does not pay in case of damage. For example, the incident may have been reported too late, documents may be missing or insured persons have provided false information about the procedure. Accordingly, it is important to get in direct contact with society in the event of damage and to describe it truthfully.
In order to avoid unpleasant surprises such as an exclusion of benefits in the event of damage, insured persons should be particularly attentive when concluding an insurance contract . In doing so, they can have individual clauses explained exactly so that they know when there is no entitlement to benefits in the event of damage.