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.
Rejection by PKV: What to do if the Private Health Insurance Rejects the Application?
Introduction
Choosing health insurance is an important financial decision. While statutory health insurance (GKV) is open to most citizens, private health insurance (PKV) offers an alternative for certain groups. But what happens if you opt for PKV, only for your application to be rejected? A rejection can cause uncertainty. This article sheds light on the reasons for a potential rejection and outlines the options available to those affected.
Fundamentals: The Dual System of Health Insurance in Germany
The German healthcare system is based on two pillars:
Statutory Health Insurance (GKV): It is founded on the principle of solidarity. Contributions are based on income, and there is an obligation to accept – everyone who meets the requirements must be admitted, regardless of their health status. A feature is the contribution-free family insurance.
Private Health Insurance (PKV): It is based on the principle of equivalence. Contributions are based on the chosen tariff, age of entry, and individual health risk. In the funded system, provisions for old age are created.
A switch to PKV is generally reserved for employees with income above the annual income threshold (JAEG), the self-employed, and civil servants.
In-depth: Reasons for Rejection in PKV
Unlike the GKV, there is no general obligation to accept in the PKV (except for the basic tariff). The main reasons for rejection are related to individual risk assessment.
Health Status and Age of Entry
Health status is a decisive factor. Before a contract is concluded, insurers conduct a health check, requiring detailed information about pre-existing conditions, treatments, and medications. Chronic illnesses or a high age of entry represent an increased financial risk for the insurer. If this risk is deemed too high by the insurer's assessment, the application may be rejected.
Options After Rejection by PKV
A rejection does not mean the end of health insurance possibilities. Since insurance is mandatory in Germany, there are always alternatives.
Remaining or Returning to GKV
For most individuals whose PKV application is rejected, the GKV is the intended solution. Those who meet the requirements (e.g., as an employee below the JAEG) remain mandatorily insured. Those who would be exempt from insurance (e.g., self-employed or employees above the JAEG) can voluntarily insure themselves in the GKV. The GKV is obligated to accept them.
The PKV Basic Tariff
An important social safety net within the PKV is the basic tariff. Private insurers are legally obligated to admit eligible individuals into this tariff without a health check.
Benefits: The scope of benefits is comparable to that of the GKV.
Contribution: The contribution is capped at the GKV maximum contribution (2025: approx. €1,218 including long-term care insurance for childless individuals). In cases of need, the contribution can be significantly reduced or waived entirely.
Waiver and Option Tariffs
For individuals who currently do not meet the requirements for their desired tariff (e.g., due to health reasons or because they are still subject to GKV-mandatory insurance), waiver or option tariffs can be a solution. They secure the current health status for a later, examination-free switch to a full PKV tariff.
Private Supplementary Insurance with GKV Retention
Those who remain in the GKV can strategically supplement their statutory coverage with private supplementary insurance (e.g., for dental prosthetics, choice of hospital services, or alternative therapies).
Recommendations for Action
Thorough Application Preparation: Answer all health questions completely and truthfully. False information can lead to loss of insurance coverage.
Professional Advice and Anonymous Risk Inquiry: An independent advisor can use an anonymized risk inquiry (RIVO) with several insurers to check if and under what conditions admission would be possible (e.g., with a risk surcharge). This is done without an official application being submitted.
Carefully Weigh Alternatives: After a rejection, examine the alternatives that suit you, such as voluntary GKV, the basic tariff, or supplementing GKV coverage with supplementary insurance.
Utilize Tax Advantages: Contributions to basic coverage in health and long-term care insurance are tax-deductible in both systems.
Summary
Rejection by PKV is possible due to risk-based calculations but does not represent a dead end. The German healthcare system ensures that every citizen receives comprehensive health insurance coverage through the GKV's obligation to accept and the legally anchored basic tariff in the PKV. Options such as private supplementary or waiver insurances offer further possibilities for individual health care planning. A careful consideration of the personal situation is essential.