A refusal letter from a Krankenkasse reads like a final answer from an institution that knows the rules. It is neither. Objecting is free, a large share of refusals are overturned, and there is one provision most people have never heard of under which a slow insurer is treated as having said yes.
1. If they take too long, it counts as approved
Statutory health insurers must decide applications within fixed periods — broadly three weeks, or five where the medical service is asked for an opinion. If they cannot meet that, they must tell you in writing, before the deadline, giving a reason and a new date.
Where they neither decide nor properly explain the delay, the application can be treated as approved by default. This is real, it is used, and almost nobody claims it because almost nobody knows the clock exists.
So the first thing to check on any refusal is not whether the reasoning is good — it is when you applied and when they answered. A refusal arriving very late, with no written explanation of the delay in between, may be vulnerable regardless of what it says.
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 ends 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, and it ends more claims than any refusal letter does. Your sick certification must be continuous, with no gap. The follow-up certificate has to be obtained in time — treat the current certificate's last day as your deadline, not the day after.
Miss it by a day and entitlement can end, whatever your medical condition. Do not let a weekend, a public holiday or a full appointment book create the gap: book the follow-up before the current note runs out.
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 have one month from receiving the decision, it 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 opening a further one-month window to go to the Sozialgericht.
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 month runs regardless. If you cannot read it quickly, file a one-line objection first and understand it afterwards.
The short version
Check the dates before you read the reasoning — a slow insurer may have already approved by default. Get the medical service's assessment and have your own doctor answer it. Never let a sick note lapse. And object within the month even if you have not yet worked out why: it costs nothing, and it is the only step that cannot be taken later.