A refusal letter from a Krankenkasse reads like a final answer from an institution that knows the rules. It is neither. Objecting is free, and an insurer that misses its decision deadline can, under conditions, end up reimbursing treatment you paid for yourself.
1. If they take too long: approval by silence
Statutory health insurers must decide applications quickly, and at the latest within three weeks of receiving them — or five where they obtain an expert opinion, usually from the medical service. Where a dental application goes through the dentists' expert procedure, the limit is six weeks. If the insurer cannot meet its deadline, it must tell you in time, in writing or electronically, and give its reasons (§ 13(3a) SGB V).
If no such notice with a sufficient reason arrives, the application counts as approved once the deadline has passed. If you then obtain the necessary treatment yourself, the insurer must reimburse the costs — within the limits below.
This does not entitle you to demand the treatment itself from the insurer. The Federal Social Court decided in 2020 that a deemed approval only gives a right to obtain the treatment yourself and be reimbursed (BSG, 26 May 2020, B 1 KR 9/18 R). That right has conditions:
- if statutory insurance does not actually cover the treatment, and you knew that — or were grossly careless not to know it — when you obtained it, the deemed approval does not get you reimbursed;
- the insurer can still decide your application, and treatment you obtain after a refusal can no longer be challenged is not reimbursed on this basis;
- applications for medical rehabilitation follow separate rules in SGB IX.
So check two things on any refusal: the dates — when you applied, any notice of delay, when they decided — and the reasons. A late refusal cannot be set aside for lateness alone. Before you pay for treatment yourself because a deadline was missed, have the dates and conditions checked.
2. The medical service is not your doctor
Refusals are commonly based on an assessment by the Medizinischer Dienst, usually made from the file, often without ever examining you.
You are entitled to know what it said, and you should ask for it. Then:
- have your treating doctors respond to the specific points it raises — a detailed report from someone who has actually examined you carries real weight against a file review;
- ask your doctor to address necessity explicitly, since that is usually the contested question rather than the diagnosis;
- keep every letter, including the envelopes.
"Not medically necessary" is an opinion formed on paper, and opinions formed on paper can be answered.
3. Sick pay, and the gap that can end it
When illness keeps you off work, your employer generally continues your pay for the first six weeks. After that, statutory sick pay (Krankengeld) takes over, at a proportion of your previous earnings, for a limited period per illness.
Here is the trap. The general rule is that Krankengeld continues if a doctor confirms that you are still unfit for work because of the same illness no later than the next working day after the last day on your current certificate. Saturdays do not count as working days for this rule (§ 46 SGB V).
If the confirmation comes later, entitlement can end. If your compulsory membership depends on your Krankengeld entitlement, there is a further safety net: the claim survives if the doctor confirms the same illness within one month of the last certified day, but no Krankengeld is paid until then (§ 46 SGB V, § 49(1) no. 8 SGB V).
Do not let a weekend, a public holiday or a full appointment book create a gap: book the follow-up before the current note runs out. If a confirmation was late, have it checked promptly rather than assuming the claim is lost.
The other frequent dispute is Krankengeld being stopped after a medical service assessment declares you fit for work. That is a decision like any other, and it can be objected to — but do it immediately, and speak to your doctor about a certificate covering the disputed period, because the gap rule keeps applying while you argue.
4. How to object
You generally have one month from receiving the decision, or three months if it was notified to you abroad (§ 84 SGG). Objecting is free, and you do not need a lawyer to file it. A valid objection needs only your details, the reference number, the date of the decision, and a sentence saying you object — with grounds to follow later if you need time.
Do not stop treatment or stop following medical advice while you object, and keep paying attention to any deadlines in parallel correspondence. Our guide to challenging a benefits decision covers the procedure in detail.
5. The social court is free
If the objection is rejected you receive a formal decision, the Widerspruchsbescheid. A claim to the Sozialgericht normally has to be filed within one month of its notification to you, or three months if it was notified to you abroad (§ 87 SGG). Read the instructions at the bottom of that decision.
For insured people these proceedings carry no court fees, and if you win, your reasonable legal costs are generally reimbursed. Legal aid exists where income is low. The financial risk is far smaller than most people assume — this part of German law is deliberately built to be accessible without money.
6. Points that catch internationals
- Statutory and private are different worlds. Much of the above applies to statutory insurance (gesetzliche Krankenversicherung). Private cover is governed by your contract and its terms, and disputes run through the ordinary courts rather than the free social courts — check which you actually have before assuming, and see our guide to private and public cover if you are still choosing.
- You can change funds. Statutory insurers offer the same core benefits but differ at the edges and in how they handle discretionary requests. Switching is possible and is not a favour they are doing you.
- Treatment abroad — planned treatment in another country, or care while visiting family — has its own rules, and refusals here are frequently worth challenging.
- No therapy place is a refusal too. A months-long wait for psychotherapy is treated by the law as the system failing to supply a benefit it owes you, and the cost of going private can fall back on the insurer — see our guide to therapy and what your Krankenkasse has to pay for.
- Arrears do not end your cover. Falling behind on contributions suspends most planned treatment but never emergency, pain or maternity care, and you cannot be dropped — the routes out are in our guide to contribution debt.
- Language is not a legal excuse, but it is a practical one. Decisions arrive in dense German and the objection period runs regardless. If you cannot read it quickly, file a one-line objection first and understand it afterwards.
The short version
Check both the decision dates and the reasons — a missed deadline can help with reimbursement, but it does not on its own secure the treatment. Get the medical service's assessment and have your own doctor answer it. Never let a sick note lapse. And object within the objection period even if you have not yet worked out why: it costs nothing, and it is the only step that cannot be taken later.