Private Patients: Access to Insurance Assessment Reports

Private health insurers often deny treatments on the grounds that evaluations of the submitted treatment documents by a consulting dentist or physician have concluded that the treatment is not medically necessary. In the overwhelming majority of cases, these expert opinions are prepared without the expert having physically examined the patient. In the past, private health insurers have countered patients’ legitimate requests for access to the expert opinion of the consulting dentist or physician with the argument that since no physical examination of the patient took place, they are not obligated to disclose the results of the assessment or the name of the expert. Furthermore, they claim it is not an obtained expert opinion but rather an internal review of the obligation to provide benefits.

The Federal Court of Justice (BGH) put a stop to this denial practice with its ruling of March 10, 2003. In its view, private health insurers must provide expert opinions they have obtained to a physician named by the policyholder, including the identity of the expert, even if no physical examination has taken place.

According to § 178 m VVG (Insurance Contract Act), the policyholder has a right against the private health insurance company to information about and access to expert opinions that the insurer has obtained to review its obligation to provide benefits regarding the necessity of medical treatment.

In the opinion of the BGH, this provision is to be understood such that the policyholder’s right of access does not depend on whether a physical examination has taken place or not. If the insurer has obtained an expert opinion from an external specialist to review its obligation to provide benefits, it is obligated to disclose it, even if the expert opinion serves the review of the insurer’s obligation to provide benefits, and thus serves internal purposes.

The BGH takes the position that only comprehensive knowledge of the content of the expert opinion and its author enables the policyholder to assess whether a claim for reimbursement of costs exists or whether the prospects of success in a lawsuit against the insurer are to be affirmed.

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