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📨 Reimbursement and refusal by your insurer

Your insurer must decide on an application promptly, as a rule within three weeks, or five with an expert opinion. If it refuses, an objection period applies.

reimbursement refusal 13 SGB V deemed approval objection self-procured service deadlines

In brief

You apply to your health insurer for a benefit. The insurer must decide promptly.

The period is three weeks. If an expert opinion is obtained, for example from the Medizinischer Dienst, it is five weeks.

If the insurer does not give a sufficient reason for a delay, the benefit is deemed approved once the period has passed.

If the application is refused, you can lodge an objection (Widerspruch). You have one month from notification.

Step by step

  1. Document the applicationSubmit the application in writing and note the date.
  2. Watch the deadlineNote when three or five weeks end.
  3. Lodge an objectionIf refused, lodge an objection. Support it with medical reasons.
  4. Get advice before paying yourselfDo not buy expensive services yourself without advice.

Deadlines

3 weeks
Insurer's decision after receipt of the application§ 13 Abs. 3a SGB V
5 weeks
Decision if an expert opinion is obtained, in particular from the Medizinischer Dienst§ 13 Abs. 3a SGB V
1 month
Objection against the notice of decision (Bescheid), from notification§ 84 Abs. 1 SGG
6 weeks
Decision in the dental expert procedure§ 13 Abs. 3a Satz 4 SGB V
Watch out – common mistakes
  • Without proof of the deadlines, deemed approval is hard to enforce. Keep a log.
  • Deemed approval gives no claim to the benefit in kind itself, only to reimbursement of costs if you obtain the service yourself (BSG 26 May 2020). Rehabilitation is excluded; §§ 14 to 24 SGB IX apply there.
  • Reimbursement for self-procured services requires that the service was necessary; in cases of wrongful refusal or failure to provide it in time.
  • The objection period is short. Do not miss it.
In depth · legal basis, figures and practice – for advisers and professionals

Insurer's deadlines (§ 13 Abs. 3a SGB V)

The health insurer must decide on an application for benefits promptly, at the latest by the end of three weeks after receipt of the application or, in cases where an expert opinion, in particular from the Medizinischer Dienst, is obtained, within five weeks after receipt of the application. If no sufficient reason is communicated, the benefit is deemed approved once the period has passed. If persons entitled to benefits obtain a necessary service themselves after the period has passed, the health insurer is obliged to reimburse the costs incurred as a result. According to BSG, judgment of 26 May 2020 – B 1 KR 9/18 R, deemed approval does not create a claim to benefits in kind, only a claim to reimbursement of costs for the self-procured service. § 13 Abs. 3a does not apply to rehabilitation services (Satz 9); §§ 14 to 24 SGB IX apply there. In the dental expert procedure the insurer decides within six weeks (Satz 4).

Reimbursement for self-procurement (§ 13 Abs. 3 SGB V)

If the health insurer could not provide an urgent service in time or wrongly refused a service, and insured persons incurred costs for the self-procured service as a result, these must be reimbursed in the amount incurred, to the extent the service was necessary.

Objection (§ 84 SGG)

The objection must be submitted within one month after the administrative act was notified to the person affected, in writing, electronically or for the record, to the authority that issued the administrative act. If notified abroad, the period is three months.

Who is responsible
  • Your health insurer
  • Social court (Sozialgericht; after the objection procedure)
  • Stiftung Unabhängige Patientenberatung Deutschland (independent patient advice foundation)
Further reading
IGeL: Services you pay for yourselfAdvice, complaints and contact points

Quick questions

Worum geht es bei „Reimbursement and refusal by your insurer“?
Your insurer must decide on an application promptly, as a rule within three weeks, or five with an expert opinion. If it refuses, an objection period applies.
Which deadlines and figures matter?
  • 3 weeks: Insurer's decision after receipt of the application (§ 13 Abs. 3a SGB V)
  • 5 weeks: Decision if an expert opinion is obtained, in particular from the Medizinischer Dienst (§ 13 Abs. 3a SGB V)
  • 1 month: Objection against the notice of decision (Bescheid), from notification (§ 84 Abs. 1 SGG)
  • 6 weeks: Decision in the dental expert procedure (§ 13 Abs. 3a Satz 4 SGB V)
What should I do first?
  • Document the application: Submit the application in writing and note the date.
  • Watch the deadline: Note when three or five weeks end.
  • Lodge an objection: If refused, lodge an objection. Support it with medical reasons.
What do I need to watch out for?
  • Without proof of the deadlines, deemed approval is hard to enforce. Keep a log.
  • Deemed approval gives no claim to the benefit in kind itself, only to reimbursement of costs if you obtain the service yourself (BSG 26 May 2020). Rehabilitation is excluded; §§ 14 to 24 SGB IX apply there.
  • Reimbursement for self-procured services requires that the service was necessary; in cases of wrongful refusal or failure to provide it in time.
Evidence
  • Gesetze im Internet, SGB V § 13, retrieved 20 September 2026
  • Gesetze im Internet, SGG § 84, retrieved 20 September 2026
As of

September 2026 · Sources and method

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