The health insurance company must pay if it reacts too late
In its decision of 22.01.2016, the Social Court in Dortmund ruled that a refusal to cover the costs of a health insurance company two and a half months after filing the application was too late.
In the case to be assessed here, the health insurance initially requested an expert opinion from the medical service and did not inform the applicant of the reasons for the delay.
The Dortmund Social Court ruled that this was a violation of the five-week deadline for a decision on the application for benefits set out in § 13, paragraph 3a, Book V of the Social Code. If the health insurance company fails to meet this deadline for deciding on a benefit application, a fiction of approval would apply.
This means that the application is considered approved.
For all patients who have been waiting for a long time for information from your health insurance company, be it for an expensive medicine, an aid or an expensive dental prosthesis, it is therefore worth taking a look at the application date. If you need legal assistance in contractual matters, it is advisable to go to a lawyer.