Is health insurance with a high deductible fair

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The basic tariff is one of the social tariffs of private health insurance (PKV). For people who can insure themselves in the basic tariff, a so-called applies Compulsory contract. This means that the insurance company must accept the applicant and not reject it - not even with the most serious previous illnesses.

Who can insure themselves in the basic tariff:

  • Privately insured, theirs Insurance contract 2009 or later completed
  • Privately insured, theirs Insurance contract before 2009 have completed and at least 55 years old, Retired or in need of assistance in the sense of social law
  • Statutory insurance within six monthsafter they became a voluntary member of the statutory health insurance
  • Uninsured with residence in Germany who are assigned to PKV (especially self-employed)

The state of health plays a role neither for the insurance cover nor for the contribution. There is therefore also no risk surcharges in the basic tariff. Nevertheless, applicants for the basic tariff may also have to answer health questions before signing a contract. On the one hand, this is necessary when you conclude a contract with the insurance company for the first time. On the other hand, it can also be useful when changing tariffs within a company: if the basic tariff offers services in some areas that were not included in your previous tariff, or if you previously had a very high deductible, so that the insurer had a poor assessment of the state of health can.

There are two reasons for a health check in the basic tariff

Basically, a health check before signing a contract is used to ensure that private health insurance can calculate the premium in accordance with the risk. In the basic tariff there are no risk-based contributions for the insured. Nevertheless, the health risk of an applicant is also important in the basic tariff for two reasons.

First: The basic tariff is co-financed by the entire community of insured persons in order to be able to fulfill these commitments for the basic tariff insured:

  • The contribution in the basic tariff is limited to the maximum statutory health insurance contribution plus the average additional contribution rate of the health insurances.
  • People in need of social assistance only pay half of the maximum contribution.
  • No risk surcharge has to be paid for previous illnesses, regardless of their severity.

The costs are shared across the shoulders of all those with private health insurance. There is a cross-company risk compensation for this. In order to be able to calculate this fairly, the PKV must know the risks of the insured. And this she learns about health issues.

Secondly: In private health insurance, the insured have the right to switch to a tariff with the same type of insurance coverage at any time. This also applies to those insured with the basic tariff. In the other PKV tariffs, risk surcharges must be paid if the health risk is increased. At the same time, if there is a tariff change to a tariff of the same type, no new risk assessment is carried out. The following principle always applies: Only the state of health at the time the contract is concluded is important. In order to resolve this contradiction, the insurers charge a fictitious risk surcharge for those with basic tariff insurance. This only becomes important for the insured when they switch to another tariff. Illnesses that occurred during the period in the basic tariff, however, are not taken into account in the contribution.

In cases of doubt, the PKV can ask the applicant to have a health check carried out by the doctor in order to better assess the risk. The insurance bears the costs for this. In doing so, the insurance company usually indicates the number of fees the doctor should use for billing.

June 2019