Partial reimbursements on expat health insurance claims usually come down to two things: a flat €25 copay fee per insured event, and a severity factor your doctor assigns to the procedure. The severity factor reflects how complex the treatment was, but reimbursement is capped at 2.3 times the base rate from the Fee Schedule for Dentists and Doctors (GOZ and GOÄ), so higher severity factors don't increase your payout beyond that cap. Doctors must provide a written explanation and get your signature when severity factors exceed certain thresholds for treatments, technical items, or lab work.
Why did I only receive a partial reimbursement for my expat health insurance claim?
Partial reimbursements for expat health insurance claims typically result from one or more of the following:
A €25 copay fee is deducted from each insured event.
The severity factor a doctor assigns to a procedure caps reimbursement at 2.3 times the base rate set by the Fee Schedule for Dentists and Doctors (GOZ and GOÄ).
Severity factors vary between doctors and cases, so reimbursement amounts can differ even for similar treatments.
What is the €25 copay fee on my expat health insurance claim?
We deduct a €25 copay fee from each insured event covered under an expat health insurance claim. This fee reduces the total reimbursement amount you receive for that claim.
What is the severity factor (Steigerungsfaktor) and how does it affect my reimbursement?
The severity factor is a number the treating doctor assigns to a medical procedure based on its difficulty and complexity. It starts at 1.00 for the simplest treatments and increases for more demanding procedures. Reimbursement is capped at 2.3 times the base rate set by the Fee Schedule for Dentists and Doctors (GOZ and GOÄ), regardless of how high the severity factor is set.
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?
Additional resources are available that explain the Fee Schedule for Dentists & Doctors (GOZ & GOÄ) and information about expat health insurance plans and enrollment.