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A child is born to parents (german citizens, german clinic) who are insured by an international private health insurance until the end of the month. The birth certificate was available at 25th of this last month of private insurance. The next month they started to be insured by a public health insurance.

§198 of Versicherungsvertragsgesetz gives the option to insure a newborn until 2 month after birth from the first day of live on. But the private insurance is not willing to take the application, because the parents are not insured there anymore. Also the public insurance is not willing to pay the bill of the birth, because the contract started after the birth.

Who is in duty here?

UPDATE: This is not about how to insure the baby. It is about which insurance is in duty to pay the bill for the baby's stay in the birth clinic.

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  • Not entirely sure, so only a comment: I don't think the newborn is exempt from mandatory health insurance. Thus, if the private health insurance happens to be correct that they don't have to insure the newborn, worst case, it should be possible to insure it for the additional one month in the "volountary mandatory" category of a public health insurance. Nov 14, 2023 at 19:56

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The minimum requirements for private health insurance ("Basistarif", base tarif) are described in § 152 of the Gesetz über die Beaufsichtigung der Versicherungsunternehmen (Versicherungsaufsichtsgesetz - VAG):

(1) Versicherungsunternehmen mit Sitz im Inland, die die substitutive Krankenversicherung betreiben, haben einen branchenweit einheitlichen Basistarif anzubieten, dessen Vertragsleistungen in Art, Umfang und Höhe jeweils den Leistungen nach dem Dritten Kapitel des Fünften Buches Sozialgesetzbuch, auf die ein Anspruch besteht, vergleichbar sind.

On first glance it seems as if international health insureres are not covered by this. But those can only conduct their business in Germany if they also fullfill the regulations of the VAG. The applicable rules differ a bit for companies from other EU countries (§ 62) and non-EU countries (§ 67 (2)), but § 152 has to be followed by all.

Sozialgesetzbuch (SGB) Fünftes Buch (V) - Gesetzliche Krankenversicherung describes in Chapter 3 the benefits the public health insurance provides, and marks those the insured have a right to ("hat Anspruch auf"). As quoted above, private insurers have to cover those required benefits in a comparable way. § 24f covers child birth:

Die Versicherte hat Anspruch auf ambulante oder stationäre Entbindung. Die Versicherte kann ambulant in einem Krankenhaus, in einer von einer Hebamme oder einem Entbindungspfleger geleiteten Einrichtung, in einer ärztlich geleiteten Einrichtung, in einer Hebammenpraxis oder im Rahmen einer Hausgeburt entbinden. Wird die Versicherte zur stationären Entbindung in einem Krankenhaus oder in einer anderen stationären Einrichtung aufgenommen, hat sie für sich und das Neugeborene Anspruch auf Unterkunft, Pflege und Verpflegung. Für diese Zeit besteht kein Anspruch auf Krankenhausbehandlung. § 39 Absatz 2 gilt entsprechend.

According to this the insured mother has a right to accomodation, care and subsistence both for herself and the newborn if she was recieved at a clinic. With the exception of treatment the child might have needed because of illness, the insurer should be liable to pay under the contract of the mother.

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  • So for the basic "stay" of the newborn, itself does not need an own insurance, right? Thank you :) Nov 13, 2023 at 21:24
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First, the public health insurer started covering you, your spouse and your baby at the beginning of the new month. So they are responsible for all health insurance cost after that date but not for anything that happened beforehand. So they will not cover a birth that happened on the 25th of the previous month.

For the private insurer I think you will need to read the fine print of how a birth is covered. A newborn would need their own contract eventually but they (probably?) don't already have it at birth. The sensible way to handle this would be to cover the birth under the insurance of the mother. Another option could be that you need to tell them before the birth and somehow register the about to be born baby with them. The payments there should work out the same way as they would have if you had stayed with the private insurer. They will have some rules on how a birth is treated but as you wrote international private insurer there is no general answer as to what these rules are.

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  • The law I mentioned in my question states, that an insurance has the duty to accept a newborn as customer, if minimum one of the parents is insured there since max. more than 3 month. AND this insurance will begin with the birth ("backwards" insured ins ome kind). But the insurance in my question see no need to pay, because the parents are not insured there anymore. Oct 31, 2023 at 19:49
  • @Allerleirauh I think you may need to get a suitable lawyer for this, at least for a proper consultation. First I would assume that child birth is in general covered by the insurance of the mum not the newborn but I don't know whether this is also true in your case. Second, if it is an international insurer they may not be aware of details of German law or maybe are aware but try to get away with their home law which is better for them. For both you would need a lawyer.
    – quarague
    Nov 1, 2023 at 0:37
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    @quarague International insurerers need a permit to operate in Germany and are acting under supervision of the Bundesanstalt für Finanzdienstleistungsaufsicht. "Trying to get away with it" would get them in serious trouble.
    – ccprog
    Nov 13, 2023 at 19:43
  • @ccprog Let's hope that the international company is aware of the German law and doesn't need a court case to convince them it applies to them. I upvoted your answer that explains the legal background.
    – quarague
    Nov 14, 2023 at 8:46
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What do you mean the public insurance (GKV) is not willing? What did they say?

Maybe it is just a simple misunderstanding? For private insurance, you need an extra insurance for every single member of your family. In the GKV, you don't. Dependents that don't work and don't have other insurance are automatically insured with you. They will get their own cards, but they will be under your contract and cost no additional fee.

Kinder, Ehegattinnen und Ehegatten sowie eingetragene Lebenspartnerinnen und Lebenspartner von Mitgliedern sind beitragsfrei familienversichert, wenn sie ihren Wohnsitz oder gewöhnlichen Aufenthalt in Deutschland haben und über ein Gesamteinkommen verfügen, das eine bestimmte Einkommensgrenze nicht regelmäßig überschreitet.

Translation:

Children, spouses and registered partners of members are covered by non-contributory family insurance if they are resident or ordinarily resident in Germany and have a total income that does not regularly exceed a certain income limit.

Lets say for example you have a stereotypical family, the husband is working, the wife stays home and now they have a kid.

  • With private insurance, the husband needs insurance. The wife needs insurance. The kid needs insurance. You pay all three rates, whatever they may be. The rates are specific to the contract of the respective person.

  • With public insurance, the husband needs insurance. The wife as a dependent with no own income is automatically insured, too and pays nothing. The kid, as a dependent with no own income is automaticall insured and pays nothing, too.

If the GKV accepted you (1), then they automatically accepted your kid (and maybe wife if she doesn't work or is under the limit). They won't accept your kid having it's own contract. That is not how they operate.

So maybe you just thought it works like private and tried to apply for their own insurance policy for your kid and they denied it because your kid is already insured through you? Maybe they just didn't explain it properly?

(1) A note for foreigners: I said "if". Public insurance is a solidarity system, where you pay the same percentage of income, whether you are a healthy 20yo or a sick 70yo. Private insurance in contrast is purely a market driven system. You pay very low rates if you are a healthy 20yo, but astronomical rates compared to your income, when you are a sick 70yo retiree. You can opt out of the public system if you make more than a certain amount of money (assuming at that point you would be able to afford the higher rates later on). But many people think only for the moment. They don't think about their 70yo self paying a market value insurance for their health on their monthly retirement payouts, that would ruin them. At some point it dawns on them, and then after having ducked the rates for decades being selfish and not showing any solidarity, they want back into the solidarity system. The solidarity system does not have to take you back if you shunned it long enough and are still rich enough to afford private. That's why I said if they take you back. But if they do, you get the full benefits. There is no "membership light" where your newborn is not insured with you (assuming your newborn isn't already self employed making a fortune on it's own).

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  • Sorry I was not precise enough. The GKV insured the baby, but not from birth. Instead from the month the family changed insurances. Oct 31, 2023 at 7:52
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    Well, that is how insurance works. They don't pay for things retroactively. Your GKV has no duty to pay anything that happens before the policy takes effect. Whether your private insurance has a duty to pay for it is between you and the private insurance, I have no idea what their conditions are.
    – nvoigt
    Oct 31, 2023 at 10:45
  • This is the reason I mentioned the law in my question... Oct 31, 2023 at 13:42
  • @Allerleirauh that law i about coverage of an already insured person however.
    – Trish
    Oct 31, 2023 at 14:53
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    May also be relevant: §192 - Typical obligations incumbent on the insurer: (1) In the case of cost-of-illness insurance, the insurer shall be obligated to reimburse any expenses for medically necessary treatment due to sickness or in consequence of an accident and for other agreed services to the agreed extent, including those expenses associated with pregnancy and childbirth, as well as outpatient medical check-ups for the early diagnosis of diseases in accordance with statutory programmes. Nov 1, 2023 at 15:49

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