(1) The health insurance may be taken out for the policyholder, or for another person. The insured person is that person for whom the insurance is taken out.
(2) Where the knowledge and the conduct of the policyholder are of legal significance under the present Act, in the case of insurance for another person, account is also taken of the knowledge and conduct of that person.
(3) Each person with a place of residence in Germany is obliged to conclude and maintain, with an insurance company licensed to operate in Germany, for himself or herself and for the persons legally represented by him or her, insofar as they are not themselves able to conclude contracts, a cost-of-illness insurance which comprises at least a cost refund for out-patient and in-patient treatment, and in which the absolute and percentage excesses for out-patient and in-patient treatment which have been agreed for services covered by the respective tariff for each person to be insured are limited to an amount of 5,000 euros per calendar year; for persons entitled to medical expenses assistance, the possible excesses emerge through the analogous application of the percentage not covered by the rate of medical expenses assistance to the maximum amount of 5,000 euros. The obligation in accordance with sentence 1 does not apply to persons who
1. are insured or subject to obligatory insurance in statutory health insurance, or
2. have a right to free treatment, to medical expenses assistance, or to comparable rights to the extent of the respective entitlement, or
3. have a right to benefits in accordance with the Asylum-Seekers Benefits Act, or
4. are recipients of recurrent benefits in accordance with the Chapters 3, 4 and 7 of Book 10 of the Social Code, and recipients of benefits in accordance with Part 2 of Book 10 of the Social Code, for the duration of the receipt of such benefits and during periods of an interruption of the receipt of benefits of less than one month if the receipt of benefits commenced prior to 1 January 2009.
A cost-of-illness insurance contract agreed prior to 1 April 2007 is deemed to meet the requirements of sentence 1.
(4) If conclusion of contract is applied for later than one month after emergence of the obligation in accordance with subsection (3) sentence 1, a premium supplement is payable. This is one month’s contribution for each further month of non-insurance commenced, from the sixth month of non-insurance one-sixth of one month’s contribution for each further month of non-insurance commenced. If it is impossible to ascertain the duration of non-insurance, it is presumed that the insured party was not insured for at least five years. The premium supplement is payable once in addition to the recurrent premium. The policyholder may demand respite from the insurer in respect of the premium supplement if the insurer’s interests can be satisfied by agreeing an appropriate payment by instalments. Interest is applied to the amount to which the respite relates. If the conclusion of the contract is applied for by 31 December 2013, no premium supplement is payable. This applies accordingly to contracts concluded by 31 July 2013 for outstanding premium supplements in accordance with sentence 1.
(5) The insurer is obliged to grant insurance in the basic tariff in accordance with section 152 of the Insurance Supervision Act
1. to all who are persons voluntarily insured in statutory health insurance
a) within six months after the introduction of the basic tariff,
b) within six months of commencement of the possibility to change envisioned in Book 5 of the Social Code in the context of their voluntary insurance agreement,
2. to all persons with a place of residence in Germany who are not subject to obligatory insurance in statutory health insurance, who do not belong to the group of individuals in accordance with no. 1, or subsection (3) sentence 2 nos. 3 and 4, and who have not already agreed private cost-of-illness insurance with an insurance company licensed to operate in Germany satisfying the obligation in accordance with subsection (3),
3. to persons who are entitled to medical expenses assistance, or who have comparable entitlements, insofar as they require supplementary insurance cover to meet the obligation in accordance with subsection (3) sentence 1,
4. to all persons with a place of residence in Germany who have agreed private cost-of-illness insurance within the meaning of subsection (3) with an insurance company licensed to operate in Germany, and whose contract is concluded subsequent to 31 December 2008.
If the private cost-of-illness insurance contract was concluded prior to 1 January 2009, on change or termination of the contract, the conclusion of a contract in the basic tariff may be demanded with the policyholder’s own insurance company, or with another insurance company, old-age reserves being carried forward in accordance with section 204 (1) only until 30 June 2009. The application must already be accepted if, in case of termination of a contract with another insurer, termination in accordance with section 205 (1) sentence 1 did not yet take effect. The application may only be rejected if the applicant was already insured by the insurer, and the insurer
1. has contested the contract of insurance because of threat or fraudulent misrepresentation, or
2. has rescinded the contract of insurance because of an intentional breach of the obligation to provide information prior to conclusion of contract.
(6) If the policyholder is in arrears in respect of an insurance policy satisfying the obligation in accordance with subsection (3) with payment in the amount of premium shares for two months, the insurer issues him or her with a reminder. In place of interest on arrears, the policyholder pays a late payment charge of 1 percent of the premium payment in arrears for each commenced month of premium payment in arrears. If, two months after receipt of the reminder, the premium payment in arrears, including the late payment charges, is higher than the premium share for one month, the insurer issues a second reminder and indicates the consequences in accordance with sentence 4. If the amount of the premium payment in arrears, including the late payment charges, remains higher than the premium share for one month after receipt of the second reminder, the contract is suspended from the first day of the following month onwards. Suspension of the contract does not come into effect, or is terminated, when the policyholder or the insured person are or become in need of assistance within the meaning of Book 2 or 12 of the Social Code; need of assistance is certified, on request by the policyholder, by the competent funding organisation in accordance with Book 2 or 12 of the Social Code.
(7) As long as the contact is suspended, the policyholder is deemed to be insured in the emergency tariff in accordance with section 153 of the Insurance Supervision Act. No risk premiums, exclusions from benefits, or excesses, apply during this period. The insurer may demand that supplementary insurance policies be suspended as long as the insurance applies in accordance with section 153 of the Insurance Supervision Act. A change to or from the emergency tariff in accordance with section 153 of the Insurance Supervision Act is ruled out. A policyholder whose contract only provides for a refund of a percentage of the expenditure incurred is deemed to be insured in a variant of the emergency tariff in accordance with section 153 of the Insurance Supervision Act providing for benefits in the amount of 20, 30 or 50 percent of the insured treatment costs, depending on what percentage is closest to the extent of the agreed refund.
(8) The insurer sends to the policyholder in text form a notification of the continuation of the contract in the emergency tariff in accordance with section 153 of the Insurance Supervision Act, and of the premium payable. In doing so, the consequences of offsetting the old-age reserve in accordance with section 153 (2) sentence 6 of the Insurance Supervision Act for the amount of the premium payable in future is indicated to the policyholder in a prominent form. The insurer may have information on insurance in the emergency tariff in accordance with section 12h of the Insurance Supervision Act noted on an electronic health card in accordance with section 291a (1a) of Book 5 of the Social Code.
(9) If all premium shares which are in arrears, including the late payment charges and the collection costs, are paid, the contract is continued from the first day of the month after next in the tariff in which the policyholder was insured prior to the occurrence of the suspension. Here, the policyholder is placed as he or she was prior to being insured in the emergency tariff in accordance with section 153 of the Insurance Supervision Act, apart from the shares of the old-age reserve used up during the suspension period. Premium adjustments and amendments to the general terms and conditions of insurance carried out during the suspension period apply from the day of continuation onwards.
(10) If the policyholder has taken the health insurance out for another person, subsections (6) to (9) apply accordingly to the insured person.
(11) In case of insurance in the basic tariff in accordance with section 152 of the Insurance Supervision Act, the insurance company may demand additional insurance policies to be suspended if and for as long as an insured person is dependent on halving the contribution in accordance with section 152 (4) of the Insurance Supervision Act.