1. compulsory insurance in private or statutory health insurance
The basic legal obligation of persons resident in Germany to maintain private health insurance is regulated in Section 193 (3) sentence 1 of the German Insurance Contract Act (Versicherungsvertragsgesetz, VVG):
Every person resident in Germany is obliged to take out and maintain medical expenses insurance with an insurance company authorised to do business in Germany for themselves and for the persons they legally represent, insofar as they cannot take out policies themselves, which covers at least reimbursement of costs for outpatient and inpatient treatment and in which the absolute and percentage deductibles agreed for outpatient and inpatient treatment for each person to be insured are limited to an amount of EUR 5,000 per calendar year.
According to § 193 para. 3 sentence 2 no. 1 VVG, however, this obligation does not apply to persons who are insured in statutory health insurance or are subject to compulsory insurance.
This therefore applies in particular to blue-collar workers, white-collar workers and those employed for their vocational training in return for pay.
The compulsory insurance of these occupational groups in the statutory health insurance scheme is in turn regulated in Section 5 Para. 1 No. 1 SGB V:
(1) The following are subject to compulsory insurance
1. labourers, salaried employees and persons employed for their vocational training who are employed for remuneration.
Naturally, most members of statutory health insurance are employees and most members of private health insurance are self-employed.
2. voluntary insurance
However, both employees and the self-employed have the option of being insured under the other form of health insurance if they fulfil the necessary requirements for exemption.
Employees have the option of taking out private health insurance if they earn more than the contribution ceiling in accordance with § 6 Para. 1 No. 1 in conjunction with § 6 Para. 5 SGB V. In conjunction with § 6 Para. 5 SGB V, employees can earn more than the contribution assessment ceiling in the long term, as they are then exempt from compulsory insurance in the statutory health insurance scheme.
Self-employed persons have the option of becoming a member of the statutory health insurance scheme in accordance with § 9 SGB V, which regulates voluntary insurance. This applies in particular to employees who become self-employed. However, § 9 Para. 1 SGB V lists other groups of people.
Joining voluntary insurance must be declared within 3 months of the end of the previous insurance in accordance with § 9 Para. 2 SGB V.
3. consequences of not being insured in the statutory health insurance scheme
There are many reasons why people who are resident in Germany are not formally insured despite the existing compulsory insurance.
People who were last covered by statutory health insurance or were not previously covered by statutory or private health insurance are nevertheless automatically covered by statutory health insurance in such cases due to § 5 Para. 1 No. 13 SGB V, which was introduced on 1 April 2007.
The start of membership in these cases is regulated in § 186 Para. 11 SGB V. According to this, membership begins on the first day on which there was no other entitlement to health insurance in Germany, i.e. on the day on which formal membership of the insurance ended and no new insurance was taken out.
As a result, uninsured members who return to their statutory insurance can regularly be required to pay additional contributions, as they were ultimately insured by law.
However, in order to mitigate the consequences of such an additional payment, the statutes of the statutory health insurance funds must provide for the possibility of waiving, reducing or deferring these retroactively levied contributions.
Remission and deferral are also regulated in § 76 SGB IV. According to § 76 Para. 2 SGB IV, the insurance institution may only
- if immediate collection would cause considerable hardship for the opposing party and the claim is not jeopardised by the deferral,
- if it is clear that recovery will not be successful or if the costs of recovery are disproportionate to the amount of the claim,
- The employer may waive contributions if their collection would be unreasonable in the individual case; under the same conditions, contributions already paid may be refunded or credited.
In the vast majority of cases, only a deferral will come into question, as the other options are associated with very high hurdles due to the solidarity concept of health insurance.
4. consequences of not having private health insurance
As mentioned above, people who cannot or do not want to join the statutory health insurance scheme are not exempt from compulsory insurance. Rather, they are also subject to compulsory insurance, namely private health insurance.
Therefore, if a person with such an obligation goes to a private health insurance company after some time without insurance in order to be insured, the private health insurance company is obliged to demand a premium surcharge from the policyholder in accordance with § 193 Para. 4 VVG.
This premium surcharge amounts to one month's premium for each additional month or part thereof of non-insurance, and one-sixth of the monthly premium for each additional month or part thereof of non-insurance from the sixth month of non-insurance.
The premium surcharge must be paid once in addition to the current premium. The policyholder may request the insurer to defer the premium surcharge if immediate payment would hit him unusually hard and the insurer's interests can be taken into account by agreeing on an appropriate instalment payment. However, interest must then be paid on the deferred amount.
Important Note: The content of this article has been prepared to the best of our knowledge and belief. However, due to the complexity and constant evolution of the subject matter, we must exclude liability and warranty. Important Notice: The content of this article has been created to the best of our knowledge and understanding. However, due to the complexity and constant changes in the subject matter, we must exclude any liability and warranty.
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