Exclusion of benefits – the facts
No insurance cover is provided for damages:
- intentionally caused by the insured person;
- caused by the insured person as a result of an intentional criminal act or the intentional attempt of
committing a criminal act.
Health insurance does not cover:
- illnesses, including their consequences, or for consequences of an accident or for death caused by active engagement in armed conflict or unrest;
- illnesses and accidents, including their consequences, caused by intent or for withdrawal and detoxification measures;
- treatment by physicians, dentists and in hospitals whose invoices have been excluded from reimbursement by the insurer for good cause if the insured event occurs after the policyholder is notified of the exclusion of benefit. If an insured event is pending at the time of notification, a duty to indemnify shall not exist for expenses incurred upon expiry of three months after the notification;
- cures, recuperative treatments and rehabilitation measures administered by the statutory rehabilitation authorities, save as otherwise envisaged by the tariff;
- treatment in a spa or health resort. This restriction shall not apply if, during a temporary sojourn, treatment becomes necessary because of an illness not connected with the purpose of the sojourn or because of an accident occurring in such a place. The duty to indemnify shall exist if departure is ruled out by medical diagnosis. The restriction shall further not apply if the treatment takes place because of residence in the spa or health resort or its immediate vicinity. The cost of therapies prescribed by the attending physician at the insured's place of residence or the insured's general practitioner is reimbursed even in case of outpatient administration in a spa or health resort;
- treatment by the spouse or partner, parents or children of the policyholder or insured; proven material expenses are reimbursed as envisaged by the tariff;
- accommodation necessitated by a need for care or detention;
- removal of cosmetic defects or physical anomalies, for vaccinations, disinfection, doctors' expert opinions, doctors' certificates or for nursing staff beyond the scope of inpatient hospital treatment, save as expressly envisaged by the tariff;
- termination of pregnancy unless unforeseen and advisable for medical reasons;
- illnesses or consequences of an accident, the treatment of which abroad was the only or one of the reasons for undertaking the travel;
- treatments whose necessity was established, subject to the journey proceeding as anticipated, before departure unless the journey was undertaken because of the death of the insured person's spouse or partner, or relation in the first degree;
- inlays, dentures, crowns or orthodontic adjustment unless the tariff expressly envisages benefits therefore;
- a regular course of pregnancy, in particular for prenatal care, and regular delivery. In the event of an acutely irregular course of pregnancy, the insurer shall grant benefits in the scope envisaged by the contract for outpatient and inpatient treatment by a physician. The same shall apply mutatis mutandis in the event of deliveries having an irregular course.
(2) If an entitlement also exists to benefits arising from statutory healthcare insurance, the insurer has a duty to reimburse for existing and known chronic illnesses as well as such illnesses and accidents including their consequences that have been treated within the last six months before the start of the insurance contract only the expenses remaining necessary despite the statutory benefits. This does not affect the exclusion of the duty to indemnify according to chapter 1 letters j) and k).
(3) Should medical treatment or an alternative measure, for which benefits have been agreed, exceed the medically required level, the insurer can reduce its benefits to an appropriate amount. If the expenses for medical care or other benefits are in a conspicuous mismatch towards the services provided, the insurer is insofar not obliged to pay.
(4) If an entitlement also exists to benefits arising from statutory accident or social security pension insurance, or to statutory therapeutic or accident welfare benefits, such benefits are to be claimed first. The insurer has a duty to reimburse only the expenses remaining necessary despite the statutory benefits.
(5) If the insured person has entitlement to benefits of several obligated parties for the same claim, the total reimbursement may not exceed the total expenditures.
You will find the detailed benefits and exclusion of benefits in the General Insurance Conditions (German).
Liability insurance does not cover:
- damages to motor vehicles as a result of keeping or operating such vehicles;
- damages caused by the exchange, transmission or provision of electronic data.
You will find the detailed terms and conditions in the Liability Insurance Conditions (German).
Accident insurance does not cover:
- accidents caused directly or indirectly by nuclear power;
- accidents as a result of mental illness or cognitive disorders;
- accidents caused directly or indirectly by foreseeable acts of war.
You will find the detailed terms and conditions in the Accident Insurance Conditions (German).
Do you require advice?
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