A Neutral Middle Ground
When a private insurer refuses a claim or applies a reduction you think is wrong, the choice is not simply “accept it or sue”. Germany operates an independent Ombudsmann for private health and long-term-care insurance — a free, neutral complaints body that reviews disputes between policyholders and insurers. It exists precisely to resolve disagreements without the cost, delay and stress of court.
Free and independent: using the Ombudsman costs you nothing, and the office is independent of the insurers. For the policyholder it is a low-risk step — you lose nothing by trying it, and it does not remove your right to go to court afterwards if needed.
What It Can and Cannot Do
The Ombudsman examines whether the insurer acted correctly under the contract and the law, and issues a decision or recommendation. For disputes up to a certain value its finding can be binding on the insurer (but not on you — you keep your court rights); above that, it issues a reasoned recommendation. What it is not is a medical second opinion or a route to rewrite your tariff: it rules on the contract as written, not on whether the tariff should have been more generous.
How to Use It
- Complain to the insurer first: raise your objection with the insurer and give it a chance to respond — the Ombudsman is the next step, not the first
- Submit in writing: set out the dispute clearly and attach the invoice, the reimbursement statement and the insurer’s reasoning
- State what you want: the specific amount or decision you are contesting
- Keep the thread: include the correspondence, so the office sees the full exchange
When to Reach for It
The Ombudsman suits disputes about claim reductions, refused benefits, or how a tariff clause was applied — the everyday friction of the reimbursement system. It is less suited to complex, high-value disputes over the legality of premium adjustments, where specialist legal advice and the courts are usually the better path. Think of it as the proportionate tool for proportionate disagreements: fast, free, and often enough to resolve a contested statement.
The Bottom Line
You are not stuck between accepting an unfair decision and hiring a lawyer. The independent PKV Ombudsman gives private policyholders a free, neutral review of a dispute, binding on the insurer up to a threshold and never costing you your court rights. Complain to the insurer first, then bring a clear, documented case — for most everyday claim disputes it is the sensible next move.
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