Partial reimbursements of expat health insurance claims can occur due to a €25 copay fee per insured event and limits based on the doctor's assigned severity factor for procedures. The severity factor reflects the complexity of the treatment and affects reimbursement amounts up to a maximum multiplier of 2.3 times the standard fee schedule. Treatments rated with higher severity factors may require a written explanation and patient consent. Variations in severity factors used by doctors explain why reimbursements may differ among claims.
Why did I receive only a partial reimbursement for my expat health insurance claim?
Partial reimbursements for expat health insurance claims can result from several common reasons.
What is the €25 copay fee on my insurance claim?
A €25 copay fee is deducted by the insurance provider for each insured event. This fee reduces the total reimbursement amount you receive.
What is the severity factor (Steigerungsfaktor) and how does it affect my reimbursement?
The severity factor is a number assigned by your doctor based on the difficulty and complexity of the medical procedure performed. It starts at 1.00 for the simplest treatments and increases with more demanding procedures. The reimbursement from your expat health insurance is capped at 2.3 times the base rate defined by the Fee Schedule for Dentists & Doctors (GOZ & GOÄ).
How does the severity factor influence the reimbursement amount?
For example, if the base rate for a treatment is €10 (severity factor 1.00), the reimbursement amounts would be:
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 |
Why do severity factors vary and affect claim reimbursements?
The treating doctor selects the severity factor based on the specific case, which means reimbursements may differ even for similar treatments. Higher severity factors are not commonly applied.
When does my doctor need to provide a written explanation about the severity factor?
If the severity factor for a treatment exceeds certain thresholds, the doctor must provide you with a written statement explaining the reason and obtain your signature before proceeding. This applies to:
Medical treatments with severity factor above 3.50
Medical technical items with severity factor above 2.50
Laboratory work with severity factor above 1.30
Where can I get more information or contact support?
If you have further questions about your expat health insurance claim or reimbursement, you can contact our support team directly.
Additional resources are available that explain the Fee Schedule for Dentists & Doctors (GOZ & GOÄ) and information about expat health insurance plans and enrollment.