72 years old, newly married since 2019, two small children. In this situation, the unthinkable happened in the life of the well-known actor Heinz Hoenig. Because of a heart condition, he was flown by rescue helicopter to a hospital in Berlin on April 30th. The situation is critical and he is scheduled to undergo emergency surgery today. According to the broadcaster RTL, for whose format “Jungle Camp” Hoenig was most recently in front of the camera, the treatment will cost 90,000 euros. The actor reportedly does not have health insurance. What happens in such cases? Who pays for the treatment? And how can you avoid getting into such situations? Answers to the most important questions.

Since 2009, every person residing in Germany has had to have health insurance. Up to a monthly income of 5,775 euros, you are required to be insured with a statutory health insurance company. Anyone who is above this income limit can take out private insurance on the first of January of the following year, or they can remain in the health insurance company as a voluntary insured person. Neither statutory health insurance companies nor private health insurance companies are allowed to terminate their members.

Theoretically, the number of uninsured people in Germany should at some point fall to zero because of this legal obligation. But compliance is hardly monitored. For example, it does not regularly cover people from other EU countries who are legally residing in Germany but do not have health insurance in their home country or here. Immigrants from third countries without valid residence status are also often not insured. There are also “long-term uninsured people” – i.e. people who were not insured before the introduction of general health insurance requirements. This group probably includes many self-employed people who never cared about it or who earned too little to pay the contributions, as well as homeless people or those whose health insurance was terminated before 2009 because of non-payment of contributions. In addition to all of these cases, there is also a special right of termination for private health insurance companies: If the member is guilty of a “pre-contractual breach of duty to disclose”, for example knowingly concealing cancer in the application for membership, the insurance company may withdraw from the contract.

According to the Federal Statistical Office, only 61,000 people in this country did not have health insurance in 2019, significantly fewer than in 2015, when there were still 79,000. However, experts assume that the number of unreported cases is high. In an article in the German Medical Journal 2022, health economist Jürgen Wasem from the University of Duisburg-Essen estimated that there would be half a million to a million people affected, while the aid organization “Doctors Without Borders” estimated a few hundred thousand people.

The health insurance of defaulters who have not paid their contributions for more than two months despite two reminders is automatically suspended. This means that although they are still insured in principle, they can only benefit from treatment for acute illnesses and pain conditions. If you are privately insured, you will be classified in a legally prescribed “emergency tariff”, for which you then only pay around 100 to 150 euros in contributions per month. For example, if a patient needs a root canal because of acute root inflammation, he or she might decide together with the dentist to try pain treatment first. Unlike the basic tariff (see below), you cannot choose the emergency tariff yourself; it is intended for exceptional financial situations.

Uninsured people can contact the statutory health insurance company of which they were previously a member. She definitely has to take them in, regardless of her current state of health. However, for the period in which you were without sufficient insurance coverage, you will be liable for contributions for the four previous years, with a late payment surcharge of one percent being charged per month. However, “contributions intentionally withheld” only become statute-barred 30 years after the due date. People who are assigned to private insurance based on their insurance history also have the right to be readmitted. You then pay the full premium retroactively for the first six months without insurance, and then one sixth of the premium. Private health insurance companies must accept them and offer them at least the so-called basic tariff, which corresponds to the scope of services offered by statutory health insurance.

Basically yes. However, this also depends, among other things, on where the person affected lives, says Robert Limmer from the clearing house of the Condrobs association for social assistance offers. “The state capital of Munich has set up its own health fund with 500,000 euros for poor people without health insurance, which covers the costs of the necessary medical services in such cases.” In such cases, Limmer acts as an intermediary and, if necessary, also organizes the transfer of the affected person to social welfare, which then pays for medical services. Dominik Heck from the Association of Private Health Insurance Companies PKV says: “In principle, the person affected or their relatives would then have to quickly submit an application for membership in a private health insurance company.” Benefits would then be paid from the day the application is submitted, i.e. before it is examined and approved. However, if the medical emergency occurred beforehand, patients may find themselves in a gray area. For example, which costs would be reimbursed if someone fell into a coma after an accident and suffered a heart attack two weeks later in the intensive care unit would have to be examined on a case-by-case basis.

Transparency note: Der stern is part of RTL Deutschland.