So far, we have dealt with social legislation in the field of social medicine. Here laws prevail, which can be substantiated by guidelines and assessment instructions and demanded through opposition and legal proceedings. Now it will go to regulations of the private insurance industry, which are also subject to laws such as the Civil Code, Insurance Contract Act and Insurance Supervision Act, but can vary considerably from insurance to insurance and from tariff to tariff. Therefore, it is very important to the contractual provisions, so the “fine print” on. Some general principles should be presented here.
Private health insurance (PKV)
The benefits of private health insurance are not tied to the profitability requirement of SGB V. Therefore, services are also paid that do not comply with the strict rules of evidence-based medicine. Increasingly, however, the private funds place higher demands on diagnostics and therapy with regard to scientific security, especially in patients with long-term high needs.
- free co-insurance of family members
- home help
- Parent (child) Cures
- Salary replacement benefits for the care of a sick child
It is sometimes difficult to obtain benefits regarding psychotherapy and inpatient rehabilitation; also aids are partially contractually limited.
In the event of incapacity for work, the private health insurance also provides wage replacement benefits, the sickness allowance, if contractually agreed. In the case of inability to work, a distinction must be made between employees (similar regulations as in the GKV) and the self-employed. The latter are usually only incapacitated for work if they are not able to work in a managerial or supervisory capacity (it is generally assumed by up to 5 employees that the self-employed person must also work here in order to run the business economically) the PKV knows the concept of partial inability to work; in the SHI, on the other hand, the "All-or-nothing rule".
On the requests of the PKV is regularly the question of occupational disability. The model conditions stipulate that the insurance ends when the occupational disability occurs and thus the payments are stopped. Here, therefore, the cross must not be set lightly.
In the meaning of the daily allowance insurance, someone who, according to medical evidence in the profession previously practiced, is more than 50% disabled for the foreseeable future is considered disabled. This term does NOT coincide with the concept of invalidity of the statutory pension insurance, so that it can happen that someone is incapacitated for work in the sense of private health insurance, but not incapacitated for the purpose of pension insurance; he will not receive any money if he is not otherwise secured.
Private accident insurance (PU)
At the PU one insures oneself against the consequences of an accident. As a general practitioner you are usually asked for information on pre-existing conditions that could affect the healing process of the consequences of an accident. First of all, however, the insurance company checks whether the damage to health is actually due to the accident in question. Finally, the consequences of accidents should be classified quantitatively. This is done by judging by the member tax, for the complete loss or complete malfunction z. For example, a limb determines the extent to which the notional reduction in earning capacity (MdE) exists. The articulated tax can be found in the General Accident Insurance Conditions (AUB). For example, the loss of one hand in the wrist will result in a MdE of 55%. Thus, 55% of the agreed sum insured would be paid out. If the functionality is still half preserved, the MdE is half of 55%, thus 27.5%. As a rule, however, this assessment is transmitted to trauma surgeons and orthopedic surgeons.
After accidents involving third-party neglect, very often car accidents, the patients are treated by our family doctors after their first presentation in the hospital or at an accident surgeon. Here is the collection of a precise finding on first contact is important because of the insurer or a court judgment on the basis of exactly elevated findings is expected.
In the form, which is usually completed, the assessment of the MdE in percent is expected in addition to anamnesis, findings and diagnosis, staggered for certain periods. It concerns here a fictitious MdE, which also z. B. in pensioners is queried.
An indication of completion could be that incapacity for work is likely to mean a 100% MdE and that it is unlikely that a MdE will drop from 100 to 0 within one day, so a certain amount of pacing is to be expected until complete healing.
In such cases, assuming appropriate findings, z. For example, a MdE of 100% for two weeks, then again over 40% for another two weeks, and finally after the last contact, in which there was no complaint, another 20% for the last two weeks to be accepted.
This is an expert opinion, which is not to be settled as a (more detailed) report, but as an opinion.
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