This article was translated from the original human-written German version. While we strive for accuracy, we cannot guarantee it is error-free. We recommend consulting the German original for the most precise information. This content is for informational purposes only and does not constitute financial or legal advice. Always consult with a qualified professional before making insurance or financial decisions.
The Health Check in Private Health Insurance (PKV): What Is It and How Does It Affect You?
The decision for health insurance is an important financial step. While statutory health insurance (GKV) is obligated by law to accept everyone, access to private health insurance (PKV) is subject to certain conditions. A central component of the application process is the health check. But what does it entail, and how does it influence your insurance coverage? This article sheds light on the role of the health check, its effects, and the differences compared to the GKV.
1. Fundamentals of the Health Check in the PKV
The PKV and the GKV are based on fundamentally different principles. In the GKV, premiums are income-dependent (solidarity principle). In the PKV, however, premiums are calculated based on individual risk (equivalence principle). This is where the health check comes into play.
It serves to fairly assess the applicant's personal health risk. The goal is a risk-appropriate premium calculation, where premiums reflect the expected healthcare costs. This approach is the basis for the PKV's funded system, where age reserves are built up to stabilize premiums in old age.
2. The Health Check Process: What Information Is Requested?
As part of the application, private health insurers ask detailed questions about the applicant's health status. Answering these questions truthfully and completely is legally required (pre-contractual duty to disclose). False or omitted information can lead to the loss of insurance coverage.
Typically, the following information is requested:
Outpatient and inpatient treatments from recent years (usually 3-5 years for outpatient, 5-10 years for inpatient).
Chronic illnesses (e.g., asthma, high blood pressure).
Planned treatments or surgeries.
Psychotherapeutic treatments.
Dental status.
General information such as height and weight (Body Mass Index).
3. Impact of the Health Check on Premiums and Benefits
The result of the risk assessment directly affects the contract. There are four possible outcomes:
Normal Acceptance: The application is accepted without conditions at the regular tariff premium.
Acceptance with Risk Surcharge: In cases of increased health risk (e.g., due to a chronic illness), a percentage or fixed surcharge is added to the monthly premium. Insurance coverage is comprehensive.
Acceptance with Benefit Exclusion: For a clearly defined, pre-existing condition, future treatments related to it are contractually excluded from coverage. This option is used less frequently and is often less recommendable than a risk surcharge.
Rejection of the Application: For very severe or multiple illnesses, the insurer may reject the application.
4. The Health Check in the Context of GKV and PKV: A Comparison
The most striking difference is the obligation to accept members in the GKV.
GKV: Statutory health insurance funds are legally obligated to accept any person who meets the requirements for membership, regardless of age or health status. There is no health check and therefore no risk surcharges.
PKV: Private insurers can conduct an individual risk assessment as part of their freedom to contract. An obligation to accept only exists for the basic tariff.
However, it is important to note: Once insured in the PKV, the contract is non-terminable by the insurer. A newly occurring illness does not lead to termination or an individual premium increase. Premium adjustments are always made for the entire tariff group and are legally regulated.
5. Special Situations: Children and Option Tariffs
There are constellations where the health check is simplified or waived:
Child Re-insurance: Newborns must be insured in a parent's tariff within two months of birth without a health check, provided the parent has been insured there for at least three months.
Option Tariffs: These secure a person's right to switch to a full PKV tariff later at their original health status. When the option is exercised, no new health check is performed.
6. Recommendations for Action
Truthful Declarations: Answer all health questions carefully and completely. If in doubt, request excerpts from your patient records from your doctors.
Seek Qualified Advice: Professional advice helps to correctly understand the health questions and evaluate the impact of potential outcomes.
Use Anonymous Risk Pre-Inquiry: To avoid rejection, which could be noted in the insurers' central warning and information file (HIS), your advisor should submit an anonymized risk pre-inquiry to several companies. This way, you receive binding offers without disclosing personal data.
Know Your Tariff Switching Rights: Even within the PKV, there is a legal right to switch tariffs according to § 204 VVG to optimize premiums if necessary, while retaining age reserves.
7. Summary
The health check is a fundamental building block of the risk-based system of the PKV. It enables individual premium calculation that follows the equivalence principle. Unlike the GKV, which has an obligation to accept members, the PKV can reject applications or agree on conditions such as risk surcharges. Truthful answers to health questions are essential. Once insured, the PKV offers lifelong, guaranteed, non-terminable protection. The health check is therefore the key mechanism that secures the functionality and the calculation basis of Private Health Insurance.