There can be a number of reasons why your claim might have only been approved for a partial reimbursement. Here we will go over a couple of the most common reasons.
The first reason is that a €25 euro copay fee is deducted by the insurance provider per insured event.
The other common reason is relating to the "Fee Schedule for Dentists & Doctors (GOZ & GOÄ)" and the "Steigerungsfaktor" (or "severity factor" in English).
A Steigerungsfaktor (severity factor) is assigned by your doctor and is related to the difficulty of a procedure. This means that a more time-consuming and demanding treatment/assessment will have a higher severity factor listed than one that is relatively simple.
The grading of severity starts from 1 (easiest) and increases in difficulty with each higher number (eg a '5' would be considered much more difficult than a '1').
Our expat health insurance policy provides a reimbursement of personal medical services up to 2.3 times the rate of the "Fee Schedule for Dentists & Doctors (GOZ & GOÄ)." You should find the severity factor listed by your doctor in any invoices provided, typically next to the cost of the treatment as shown below.
Let's now go through an example of a physical assessment, and in this case, let's just say that the base rate of this treatment is €10 (Steigerungsfaktor 1.00). Below is a table of how this cost would be reimbursed if the treating doctor or medical specialist rated the treatment with a higher severity factor.
Severity factor | Total cost of treatment | Reimbursement |
1.00 | €10 | €10 |
2.00 | €20 | €20 |
2.30 | €23 | €23 (max reimbursement) |
3.50 | €35 | €23 |
5.00 | €50 | €23 |
We unfortunately cannot determine the severity factor chosen as this is determined by the treating doctor, and this is why reimbursements can sometimes vary, but please do note that the highest severity factor is not commonly applied.
Additionally, if the severity factor will be above a certain number for a given treatment or assessment, then, by law, your treating doctor is required to provide you with a written statement explaining why this is and needs a signature of your consent before proceeding with the treatment. This statement is required for the following:
For medical treatments (persönliche Leistungen) above 3.50 severity factor
For medical technical items (medizinisch-technische Leistungen) above 2.50 severity factor
For lab work (Laborleistungen) above 1.30 severity factor
If you have any further questions, please don't hesitate to contact us.
You can also read further about the GOÄ & GOZ schedule of fees in our FAQ here.
If you would like to learn more about expat health insurance or would like to sign up, you can do so here.