A medical history assessment is a review of a private health insurance (PKV) policy to establish whether a medical condition existed before coverage began. It is normally triggered when a submitted bill or treatment plan relates to a condition that may have predated enrollment. Payment of affected medical bills is held while the assessment runs, and settled retroactively if coverage stays in place. The process is set by the pre-contractual duty of disclosure under §19 of the German Insurance Contract Act (Versicherungsvertragsgesetz, VVG), and a decision usually follows within 4 weeks of receiving all required information.
What is a medical history assessment on private health insurance (PKV)?
A medical history assessment is a formal review of your private health insurance (PKV) policy to establish whether a medical condition existed before your coverage began. The review is governed by the pre-contractual duty of disclosure set out in §19 of the German Insurance Contract Act (Versicherungsvertragsgesetz, VVG). It checks the medical information you gave when you applied against the medical history on record with your doctor or your previous insurer.
Why did a medical history assessment start on my private health insurance (PKV) policy?
A medical history assessment is normally triggered when a bill or treatment plan you submit relates to a condition that may have existed before your private health insurance (PKV) coverage began. The trigger is the condition's possible start date, not the size or type of the claim.
What happens to my medical bills during a medical history assessment?
Payments for medical bills are generally placed on hold until the assessment is completed. You are responsible for providing all required information, including responses from your doctor or other third parties. Once a decision has been made and coverage remains in place, any payments that were on hold will be processed retroactively.
What are the steps in a medical history assessment?
The assessment runs in 4 steps. Hallesche runs the review, so all correspondence about it comes from Hallesche rather than from us. It arrives in the Hallesche4u app, or by post to your home address if you have not switched your correspondence to electronic delivery in the app.
Submit the required form. Complete and return the form the provider sends you. This usually includes:
A confidentiality release authorizing Hallesche to contact your doctor
A questionnaire about your medical history
The provider contacts the relevant parties.
Once your documents are received, Hallesche writes to your doctor and, where relevant, your previous insurer by post. Telling your doctor in advance that a request is coming helps avoid delays.
Provide additional information if it is requested.
In some cases, the team may request further details, such as an additional confidentiality release or clarifications about your medical history.
Receive the decision.
After all information has been reviewed, Hallesche issues a decision, usually within 4 weeks, and sends it to you in the Hallesche4u app or by post.
If no concerns are identified, any pending medical bills will be paid.
If the review identifies a contractual discrepancy, the team will inform you of the outcome and explain any resulting adjustments to your policy.
What are the possible outcomes of a medical history assessment?
Most medical history assessments close with no change to the policy, and the medical bills on hold are paid. Where the review finds that relevant medical information was not disclosed at application, your private health insurance (PKV) policy can be adjusted in one of the following ways:
An exclusion is added, so treatment for the undisclosed condition is not covered.
A surcharge is added to your premium to reflect the undisclosed condition.
In rare cases involving serious non-disclosure, the private health insurance (PKV) policy is canceled.
What am I responsible for during a medical history assessment?
You are responsible for returning every requested document and for making sure your doctor or any other party we contact responds. The assessment cannot progress while a required response is outstanding, so timely submission helps avoid delays in the assessment.