Schlichtungsantrag beim Ombudsmann für private Kranken- und Pflegeversicherung stellen

To ensure that differences of opinion between you and your private health or long-term care insurance can be resolved without lengthy legal disputes, the insurers have set up an out-of-court arbitration procedure. The ombudsman helps you to settle differences quickly and unbureaucratically.

HINT: Before you can contact the Ombudsman's Office, you must first address your complaint directly to your insurance company. This gives the company the opportunity to reconsider or better justify its decision. Often, correspondence or a personal conversation can completely avoid a dispute.

Mediation and consultant disputes

The Ombudsman's Office is also responsible for complaints against insurance intermediaries if the disputed facts relate to the successful or attempted mediation of private health and long-term care insurance. You can also contact the ombudsman if you have disputes with insurance consultants in connection with the conclusion of insurance contracts.
Preconditions

• The applicant is a natural person in an existing or terminated insurance relationship.

HINT: If you are insured with the Postbeamtenkrankenkasse (PBeaKK) or the Krankenversorgung der Bundesbahnbeamten (KVB), the ombudsman can only accept complaints relating to compulsory long-term care insurance.

• A complaint lodged by the insured with the insurance company concerned was unsuccessful.
• The insurance company concerned must have joined the ombudsman procedure.

Exceptions

Conciliation by the ombudsman is not possible in the following cases:

• the conflict has already been settled by an out-of-court settlement
• the conflict was or is already the subject of arbitration proceedings at another ombudsman's office or at the Federal Financial Supervisory Authority (BaFin).
• an application for legal aid was dismissed because the action had no prospect of success
• the dispute is dealt with in a court before or during the conciliation proceedings or is brought to court by the applicant during the conciliation proceedings
   

• Complaint form
• Documents necessary to understand your case, in particular:
  • the current correspondence with the private health or long-term care insurance concerned on the facts of the case

If you do not submit your complaint yourself:

• Power of attorney form
  Only required if you do not use the complaint form or the online complaint:
• Declaration of release from confidentiality

If necessary, the ombudsman will request further documents from you.

ATTENTION! Please do not send originals, but only copies.

The procedure is free of charge for you. There are only costs for postage and, if necessary, for copies.

Complaint to the insurance company

• Before contacting the ombudsman, first address your complaint to your insurance company. This gives the company the opportunity to reconsider or better justify its decision.

HINT: The ombudsman can only take action if this direct attempt to clarify and reach an agreement has failed or if the insurer has not responded to your complaint within 6 weeks.

Check jurisdiction

• Check whether the insurance company concerned has joined this procedure.

Request for conciliation

• If all requirements are met, submit the complaint online or in writing by post or fax to the ombudsman.

TIP: On the Ombudsman's website, you can submit your complaint easily and conveniently online.

• If you wish to submit a complaint by post or fax, please use the complaint form on the Ombudsman's website:
• Fill in the form as completely as possible. Describe the facts and what you want to achieve with your request for conciliation.
• Attach copies of all relevant documents necessary to understand the concern.
• The ombudsman for private health and long-term care insurance will confirm receipt of the complaint and send you a description of the further course of the proceedings.

Explanations on how to submit the complaint and on the course of the ombudsman procedure can also be found on the website of the Ombudsman for Private Health and Long-Term Care Insurance.

• Requests for conciliation are possible
  • within one year of the insurer's act or decision. The deadline is suspended by filing a prior written complaint with the insurer for a maximum period of 6 weeks.
  • at the earliest 6 weeks after your complaint has been received by the insurer and you have not received a written decision from the insurer.
• The ombudsman procedure suspends the limitation period for claims.
   

Other

If no mediation can be reached through the ombudsman procedure, you can contact the Federal Financial Supervisory Authority or assert your claim in court proceedings.