PKV: Full coverage for Hartz IV recipients



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Privately insured recipients of Hartz IV benefits are entitled to full PKV contributions

So far, the job centers have refused to pay the full cost of private health insurance (PKV) for those receiving Hartz IV benefits. Only the minimum rate of the statutory health insurance was taken over. The Federal Social Court in Kassel now strengthened the back of those affected. The job centers must now bear the full costs.

On January 18, 2011, the 4th Senate of the Federal Social Court decided in proceedings B 4 AS 108/10 R that the plaintiff, who works as a self-employed lawyer and is privately insured (private health insurance), is deprived of the basic security for jobseekers in the period in 2009 May demand full coverage of his contributions to private health insurance.

The plaintiff could no longer automatically become a member of statutory health insurance - as was the case until 31 December 2008 - as a recipient of subsistence benefits under SGB II, but had to pay his private health insurance with a premium of EUR 207.39 maintained. There is no explicit regulation on how the open contribution share is to be balanced in SGB II.

In this respect, there is a loophole inherent in the law in the sense of an incomplete incompleteness of the legal regulations. The legal material for the GKV Competition Strengthening Act does not provide sufficient evidence that the legislature deliberately and intentionally wanted to leave the privately health-insured recipients of subsistence benefits under SGB II a contribution that they did not bear financially. The written motifs contain references to an "affordable basic tariff" and regulations that take this into account, which ensured that "those affected would not be financially overwhelmed". The further regulatory context also speaks for a gap inherent in the law, because contributions for voluntarily health-insured beneficiaries are taken over in full and contributions to private health insurance in cases, in which the need for help according to SGB II can be avoided.

Finally, the constitutionally guaranteed subsistence level of privately insured SGB II beneficiaries would be affected if the contributions they owed to private health insurance were not borne by the institution of the basic insurance. The unscheduled regulatory gap in the payment of contributions to private health insurance must be closed - with regard to the open contribution shares - by an analogous application of the regulation for persons insured voluntarily in statutory health insurance. This results in the defendant's obligation to pay the full amount. (Az .: B 4 AS 108/10 R)

Notes on the legal basis:
Section 26 Subsidy for insurance contributions ...
(2) For recipients of unemployment benefit II or social benefits who are not subject to compulsory health insurance and are not covered by family insurance and who are in the event of illness

1. are insured with a private health insurance company, section 12 (1c) sentences 5 and 6 of the Insurance Supervision Act apply,
2. if you are voluntarily insured in the statutory health insurance, the contribution is paid for the duration of the benefit; for people who would be in need of help solely through the contribution to voluntary insurance, the contribution will be covered to the extent necessary.

The contribution is also covered to the extent necessary for persons who are subject to compulsory health insurance and who would only need help from the health insurance contribution.

§ 12 VAG ...
1c) The contribution for the basic tariff without deductible and in all deductible levels may not exceed the maximum contribution of the statutory health insurance; … .If the need for help in the sense of the second or twelfth book of the Social Code arises solely from the payment of the contribution according to sentence 1 or sentence 3, the contribution is reduced by half for the duration of the need for help; the need for help is to be checked and certified by the responsible institution in accordance with the Second or Twelfth Book of the Social Code at the request of the insured person. If there is a need for help within the meaning of the second or twelfth book of the Social Code, even in the case of a reduced contribution according to sentence 4, the responsible institution will participate in accordance with the second or twelfth book of the social code at the request of the insured person, insofar as this avoids the need for help. If there is a need for help according to the Second or Twelfth Book of the Social Code regardless of the amount of the contribution to be paid, sentence 4 applies accordingly; the responsible institution pays the amount that is also to be borne for a recipient of unemployment benefit II in the statutory health insurance.

Also read:
New special regulations for changing PKV
Hartz IV: 13 health insurance companies charge an additional contribution
Exemption from additional contributions at Hartz IV
Study: fear of Hartz IV makes you sick
Health insurance companies Additional contributions: Switch is worthwhile

Image: Matthias Balzer / pixelio.de

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