(1) In the case of cost-of-illness insurance, the insurer is obliged to reimburse any expenses for medically necessary treatment due to sickness, or in consequence of an accident, and for other agreed services to the agreed extent, including those expenses associated with pregnancy and childbirth, as well as out-patient medical check-ups for the early diagnosis of diseases in accordance with statutory programmes.
(2) The insurer is not liable to pay claims in accordance with subsection (1) insofar as the expenses for treatment or other services are manifestly disproportionate to the services performed.
(3) The contracting parties may agree that the content of the cost-of-illness insurance contract covers additional services directly linked to those referred to in subsection (1), especially
1. providing advice regarding the services referred to in subsection (1), as well as regarding the providers of such services;
2. providing advice regarding the entitlement to remuneration of those providing the services referred to in subsection (1);
3. avoiding unauthorised entitlements to remuneration of those providing the services referred to in subsection (1);
4. providing support to insured persons when asserting claims on account of the incorrect provision of the services referred to in subsection (1) and the consequences resulting therefrom;
5. directly settling accounts for services referred to in subsection (1) with the providers thereof.
(4) In the case of daily hospital allowance insurance, the insurer is obliged to pay the agreed daily hospital allowance for medically necessary in-patient treatment.
(5) In the case of daily sickness allowance insurance, the insurer is obliged to reimburse the earnings lost as a result of the illness or accident due to the incapacity to work by paying the agreed daily sickness allowance. He or she is furthermore obliged to compensate for the loss of earnings occurring during the protection periods in accordance with section 3 (1) and (2) of the Maternity Protection Act (Mutterschutzgesetz), and on the day of delivery, by the agreed daily sickness allowance, unless the insured person is entitled to other reasonable compensation for the loss of earnings caused during this period.
(6) In the case of long-term nursing care insurance, the insurer is obliged, in the event of the need for long-term nursing care, to reimburse to the agreed extent the expenses for caring for the insured person (long-term nursing care costs insurance), or to pay the agreed daily allowance (daily long-term nursing allowance insurance). Subsection (2) applies accordingly to long-term nursing care costs insurance. The provisions of Book 10 of the Social Code concerning private long-term nursing care insurance remain unaffected.
(7) In the case of cost-of-illness insurance in the basic tariff in accordance with section 152 of the Insurance Supervision Act, and in the emergency tariff in accordance with section 153 of the Insurance Supervision Act, the service-provider may also assert his or her claim to remuneration for services provided against the insurer insofar as the insurer is obliged by the insurance agreement to effect payment. The insurer and the policyholder are liable as joint and several debtors as concerns the obligation incumbent on the insurer to effect payment emanating from the insurance agreement. Insofar as the insurer provides the payment to the service-provider, or to the policyholder, in the emergency tariff in accordance with section 153 of the Insurance Supervision Act owed from the insurance agreement, it is released from its obligation to effect payment vis-à-vis the service-provider. The insurer may not offset in the basic tariff in accordance with section 152 of the Insurance Supervision Act, and in the emergency tariff in accordance with section 153 of the Insurance Supervision Act, an insurance premium due to it from cost-of-illness insurance or private compulsory long-term care insurance against a claim of the policyholder from these insurance policies. Section 35 does not apply.
(8) Prior to commencing medical treatment the cost of which is likely to exceed 2,000 euros, the policyholder may demand information from the insurer in text form regarding the extent of insurance cover for the intended medical treatment. If the implementation of the medical treatment is urgent, the insurer issues information without delay, accompanied by reasoning, at the latest after two weeks, otherwise after four weeks; attention is paid here to a cost estimate submitted by the policyholder, and to other documents. The period commences on receipt of the request for information by the insurer. If the information is not issued within the period, it is presumed until proof of the contrary by the insurer that the intended medical treatment is necessary.