Billing and insurance

For members of statutory insurance companies, the conditions from the regulations in Section 27a SGB V and further guidelines apply. Before treatment, a treatment plan must be submitted to the health insurance company. The partners must be married to each other. There are also age limits. Both partners must be have passed their 25th birthday. The woman must not have reached her 40th birthday or the man his 50th birthday. 50% of the costs will be covered for a maximum of three attempts of IVF or ICSI treatment or for eight inseminations. It is crucial that the principle person applies. This means that a health insurance company reimburses only those costs that arise for the treatment of its insured member. The insurance of the partner is not valid.

For privately insured persons, the specific insurance contract is decisive. The specific Terms and Conditions of Insurance and the tariff conditions govern whether, and to which extent, costs in the field of “artificial insemination” are reimbursed. It is imperative to review these. As a general rule, no prior approval is necessary. The partners do not need to be married to each other. The causation principle applies. This means that, in addition to other requirements, the health insurance company is only obligated to reimburse fees if the insured person causes need for the treatment. In this, case, as a general rule, 100% of the treatment costs will be reimbursed, if certain chances of success are given. To this end, the BGH has judged that a medical probability of 15% must be given. As long as this is given, in many cases the number of attempts is not limited.

For persons entitled to financial aid, the regulations in the aid rules of the individual States and of the Federal Republic apply, as well as their administrative regulations. All financial aid ordinances take the view that the regulations in Section 27a SGB should apply. In this way, financial aid can be viewed in principle as being like a statutory health insurance company with the specified regulations in Section 27a SGB V.

Fertility treatment is recognised as a medically necessary treatment and is not rejected because the fitness of police officers and soldiers to serve is not affected. The Federal Administrative Court has decided that in principle the State aid law is to be applied.

As a general rule, a taxpayer can receive a reduction of income tax based on the costs of their fertility treatments. According to the jurisdiction of the Federal Finance Court, the costs of a couple who cohabit without being married and the costs of heterologous treatment with donor semen are also recognised.

For State support of up to 25% of the statutory co-payment, the Federal funding guideline states as a basic condition that aid money is paid in the Federal State in which the couple lives. At present at least, not all federal states of Germany participate in this program.

Due to the different derivations of the reimbursement of costs, problems arise mostly when“mixed circumstances”are present. This applies if both partners are not insured by the same health insurance company or if one partner has statutory health insurance and the other has private health insurance. In this case, the rigid rules in Section 27a BGB V clash with the private system of the causation principle and the prospects of success. If one partner is additionally entitled to aid, then claims arise against several payers,which should be known. The network requires an individual assessment in every case.

The contributory causation of the need for fertility treatment by both partners should be checked. In many cases, private health insurance companies claim that their insured member was not the cause of the treatment. However, this does not necessarily mean that the other partner has absolutely no chance.

The most frequent problems arise due to a private health insurance company’s claim that the there is no indication for treatment, the other partner is the cause, or the chances of success are lower than 15%. Also, the AMH value is used or, recently, also the evaluation of the spermiogram. Here, medicine and the law must work together on the basis of the specific findings.

It must be borne in mind that the referral to another insurance company is against the law. The BGH and the BSG have judged that one insurance company cannot make its reimbursement of costs dependent on the services of another insurance company. For this purpose no health insurance company can demand information and documents about the
other.

The costs of cryopreservation (i.e. for freezing ova) are categorically not reimbursed because it does not constitute a treatment. However, there are a few exceptions from this principle.

The treatment costs of heterologous treatment with donor semen are, at present, not reimbursed by either the statutory health insurance companies or by private health insurance. The heterologous treatment with donated ova is forbidden by the ESchG.

The health insurance companies cannot interfere with the medical planning of the treatment . This is in the hands of the couple, together with the doctors, and is based on the specific medical findings.

This representation serves as an initial general introduction to the topic. An individual assessment is recommended.

Text: Andreas Maria Wucherpfennig, Lawyer, info@ra-wucherpfennig^.de, mobile: 0151 24071888, www.ra-wucherpfennig.de