In Germany, the public health system (Gesetzliche Krankenversicherung or GKV) and private health insurance (Private Krankenversicherung or PKV) are the two main types of healthcare coverage. Each system has distinct features, and understanding how they work, especially in the context of accident claims and compensation, is essential. Here’s a breakdown of each and how they interrelate, particularly after an accident:
1. Public Health System (Gesetzliche Krankenversicherung – GKV)
Germany’s public health system is based on the principle of solidarity, meaning everyone is required to contribute to the system, and healthcare is provided according to need, rather than individual wealth.
Key Features of the Public Health System:
- Mandatory for most residents: If you’re employed and earn below a certain threshold (around €66,600 per year in 2025), you must be covered by the public system. Many self-employed people, students, and retirees also qualify for GKV.
- Universal coverage: GKV covers a wide range of medical treatments, including doctor visits, hospital stays, prescriptions, mental health care, and rehabilitation.
- Contributions based on income: Contributions to the public system are income-based, with both the employer and the employee contributing to the costs. The total contribution is approximately 14-15% of your gross salary.
- Co-pays: While GKV covers a lot of treatments, there are still co-pays for certain services, such as doctor visits, hospital stays, or medications. However, these co-pays are typically low.
- Treatment quality: Public insurance usually covers basic and essential medical services, but the quality and speed of care may not be as high as in the private system, particularly in terms of waiting times or access to more specialized treatments.
Public Insurance in the Event of an Accident:
- If you’re involved in an accident, your public health insurance will generally cover your immediate medical treatment, hospital stays, and rehabilitation, regardless of whether you’re at fault.
- However, if the accident was caused by another party (e.g., a car accident), the responsible party’s liability insurance will usually cover the medical costs.
- The public insurance will cover your medical costs initially and later recover the expenses from the at-fault party’s insurance company. This process is handled by your lawyer.
2. Private Health Insurance (Private Krankenversicherung – PKV)
Private health insurance offers more flexibility and typically provides a higher level of service compared to the public system. However, it is optional and generally available to those who:
- Are self-employed.
- Earn above a certain income threshold (currently around €66,600 per year).
- Are civil servants (they often have special benefits).
Key Features of Private Health Insurance:
- Higher premiums: The premiums for PKV are based on individual risk factors, such as age, health status, and the level of coverage. Unlike GKV, premiums are not income-based. This can lead to lower premiums for healthy, young individuals but significantly higher premiums for older individuals or those with pre-existing conditions.
- Broader coverage: PKV typically offers a broader range of services, including:
- Private hospital rooms or faster access to specialists.
- Choice of doctors: Patients can often choose to see specific doctors or specialists without the waiting times typically associated with public health insurance.
- Faster treatments: With private insurance, you often experience shorter waiting times and higher-quality medical care.
- Reimbursement model: With PKV, you usually pay upfront for medical treatment and then get reimbursed by the insurance company. This can be an issue for individuals who don’t have the funds to pay upfront.
Private Insurance in the Event of an Accident:
- If you’re covered by private health insurance, it will also cover the cost of medical treatments and hospital stays. The benefits for accident victims can be more comprehensive than the public system, covering private hospitals, additional therapies, or more advanced treatments.
- In the case of an accident, your private insurer will cover the medical costs, and like with public insurance, it may later seek reimbursement from the at-fault party’s insurance.
- Out-of-pocket costs: While PKV offers a higher level of care, it’s important to remember that individuals with private insurance often face higher upfront costs (for treatment) before they get reimbursed. If you’re involved in an accident, you might need to cover those costs until the insurance settles.
3. How Public and Private Health Insurance Work Together in Accident Cases
Here’s how both systems generally work in the context of an accident:
- First step: Immediate Medical Treatment
- Public insurance (GKV) will cover the medical bills immediately. If you have private insurance, you can opt for private care, but GKV will still pay for the treatment at the base level.
- Second step: Recovery of Costs
- If the accident was caused by another party (e.g., another driver in a car accident), both public and private insurers have the right to claim compensation from the responsible party’s liability insurance.
- In this case, the at-fault party’s liability insurance (Haftpflichtversicherung) will cover the medical expenses that were initially paid by your insurer. This applies regardless of whether you are covered by GKV or PKV.
- Third step: Pain and Suffering Compensation
- In addition to medical expenses, accident victims are entitled to compensation for pain and suffering (Schmerzensgeld). This is negotiated separately and doesn’t depend on whether you have public or private insurance. The amount will depend on the severity of the injury.
4. What Happens if You Have Both Public and Private Insurance?
Some individuals in Germany have a combination of both public and private insurance, which could happen in two scenarios:
Dual Insurance for Supplementary Coverage (Zusatzversicherung)
- Supplementary insurance is often used by those covered under the public system who want to access more services available through private insurance (e.g., private rooms in hospitals, or dental treatments). This is an additional layer of insurance to provide more benefits, but the primary public insurance still covers most of the basic medical care.
Combination of Private and Public Insurance
- For higher-income individuals, especially those who switch to private insurance for certain aspects (e.g., dental care, specialist access), the basic healthcare needs would still be covered by the public system.
- Reimbursement process: If you’re involved in an accident and covered by both, the reimbursement process is still similar — the primary insurer (usually public health insurance for most people) pays the costs upfront and may seek compensation from the at-fault party’s insurer. The private insurance may cover additional costs not covered by the public system.
5. Important Points to Remember:
- Accident-related medical costs: Whether you have public or private insurance, you should be covered for medical expenses related to accidents, and your insurer will typically seek reimbursement from the at-fault party’s liability insurance.
- No upfront payments (for public health insurance): In the public system, you generally don’t have to worry about upfront payments — the insurance pays directly to the hospital or doctor.
- Reimbursement (PKV): For private health insurance, you may need to pay upfront for treatment, and the insurance company will reimburse you later.
- Accident lawyer’s role: In an accident claim, the accident lawyer can assist you in making sure that your medical bills, lost wages, and any other damages are compensated by the responsible party’s insurance, whether you’re covered under the public or private system.
6. When to Consult a Lawyer
If you’re involved in an accident and have any of the following issues, it’s advisable to consult a lawyer:
- Liability disputes: If there’s a dispute over who caused the accident, a lawyer can help gather evidence and represent you.
- Reimbursement issues: If the responsible party’s insurance is not compensating you fairly or is delaying payments.
- Personal injury claims: If you’re entitled to pain and suffering compensation, a lawyer can ensure you get the maximum possible settlement.