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Gothaer BarmeniaGothaer Beihilfeergänzung Genau-Für-Sie Ergänzung: the policy wording in full
Beihilfeergänzungstarif der Barmenia Krankenversicherung AG (BarmeniaGothaer) für verbleibende Kosten bei Sehhilfen (200 EUR in zwei Kalenderjahren), Fehlsichtigkeit und Zahn nach Beihilfe und Tarif Genau-Für-Sie Krankenversicherung, Zahnersatz in den ersten beiden Kalenderjahren bis 5.000 EUR.
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Everything about this policy
What the policy covers: 70 points, each with its clause
Quotes are shortened.
The full German wording of each point is on the German page for Gothaer BarmeniaGothaer
Beihilfeergänzung Genau-Für-Sie Ergänzung.
Basics and link to the state allowance
| Point | Rule | Wording (German) | Clause |
|---|---|---|---|
| Eligible persons (civil servants, judges, pensioners, dependants, trainees) | yes | „können Personen versichert werden, die Anspruch auf Beihilfe haben. Das gilt auch für …“ | A. Vorbemerkung, page 2 |
| Reimbursement levels matching the allowance rate (for example 20, 30, 50 per cent) | yes | „unabhängig von der Höhe Ihres individuellen Beihilfe-Bemessungssatzes. Dies gilt auch …“ | A. Vorbemerkung, page 2 |
| Total reimbursement from allowance and insurance capped at 100 per cent of costs | not addressed | ||
| Adjustment to a changed allowance rate or loss of the allowance without new health check (deadline) | not addressed | ||
| Change of reimbursement level on retirement (for example from 50 to 30 per cent) | not addressed | ||
| Valid for the allowance rules of the federation and all federal states | not addressed | ||
| Tariff or dormant cover for recipients of free medical care (police, fire service, armed forces) | not addressed | ||
| Admission under the industry opening scheme (no exclusion, surcharge at most 30 per cent) | not addressed | ||
| Free choice of doctors, dentists and hospitals | not addressed | ||
| Reimbursement above the maximum rate of the fee schedule | yes | „Wir erstatten die Gebühren für ärztliche und zahnärztliche Leistungen im tariflichen …“ | B. Hinweis, page 2 |
Outpatient benefits
| Point | Rule | Wording (German) | Clause |
|---|---|---|---|
| Outpatient medical treatment at the tariff percentage | not addressed | ||
| Medicines and dressings (including non-prescription) | not addressed | ||
| Naturopaths and natural therapies (annual maximum) | not addressed | ||
| Therapies (physiotherapy, occupational therapy, speech therapy) | not addressed | ||
| Therapies only up to the amounts eligible for the allowance | not addressed | ||
| Medical aids with an open catalogue | not addressed | ||
| Glasses and contact lenses (amount and period) | yes, up to EUR 200 | „Die verbleibenden Kosten für Sehhilfen (auch Sonnenbrillen mit Sehstärke) …“ | B. 1 a), page 3 |
| Hearing aids (amount per ear and period) | not addressed | ||
| Outpatient psychotherapy (rate, approval) | not addressed | ||
| Psychotherapy limited to a number of sessions | not addressed | ||
| Check ups and vaccinations (also beyond statutory programmes) | not addressed | ||
| Home nursing and palliative care | not addressed | ||
| Travel and transport costs (ambulance, journeys to outpatient treatment) | not addressed | ||
| Fertility treatment (conditions, number of attempts) | not addressed |
Inpatient benefits
| Point | Rule | Wording (German) | Clause |
|---|---|---|---|
| General hospital services (shared room, ward doctor) | not addressed | ||
| Two bed room as optional service | not addressed | ||
| Single room as optional service | not addressed | ||
| Treatment by senior consultant of choice | not addressed | ||
| Optional hospital services at 100 per cent where the employer does not grant an allowance for them | not addressed | ||
| Treatment in private clinics without public contract | not addressed | ||
| Hospital daily allowance or substitute allowance when optional services are not used | not addressed | ||
| Follow up treatment and inpatient rehabilitation | not addressed | ||
| Spa and sanatorium treatment (subsidy, interval between two stays) | not addressed | ||
| Inpatient psychotherapy and psychiatry (days, prior approval) | not addressed |
Dental
| Point | Rule | Wording (German) | Clause |
|---|---|---|---|
| Dental treatment and prophylaxis | yes, up to the sum insured | „Die verbleibenden Kosten für zahnärztliche Behandlungen des Tarifs Genau-Für-Sie …“ | B. 2, page 3 |
| Dentures (crowns, bridges, prostheses) | yes, up to the sum insured | „Die verbleibenden Kosten für Zahnersatz sowie Zahn- und Kieferregulierung ersetzen wir …“ | B. 2, page 3 |
| Implants (number per jaw, link to cases eligible for the allowance) | yes, up to the sum insured | „Dazu zählen zum Beispiel: - Prothesen, - Stiftzähne, - Brücken, - Kronen, - Implantate“ | B. 2 c), page 3 |
| Material and laboratory costs at the tariff percentage | not addressed | ||
| Orthodontics (children, adults) | yes, up to the sum insured | „Vor- und Nachbehandlungen (zum Beispiel Knochenaufbau) und Reparaturen sowie - Zahn …“ | B. 2 c), page 3 |
| Caps on dentures in the first policy years | yes, up to EUR 5,000 | „In den ersten beiden Kalenderjahren zusammen maximal 5.000 EUR. - Ab dem dritten …“ | B. 2, page 4 |
Supplement and allowance gaps
| Point | Rule | Wording (German) | Clause |
|---|---|---|---|
| Supplementary tariff for costs the allowance does not or only partly recognise | yes | „Der Tarif Genau-Für-Sie Ergänzung übernimmt die verbleibenden Kosten für Sehhilfen …“ | B. Hinweis, page 2 |
| Supplement pays only after a decision of the allowance office | none | „Sie erhalten die tariflichen Leistungen auch dann, wenn die Beihilfe nicht vorleistet …“ | B. Hinweis, page 2 |
| Compensation of the cost dampening lump sum or the allowance retention | no | „Die in den für Sie gültigen Beihilfevorschriften festgelegten Kostendämpfungspauschalen …“ | B. Hinweis, page 2 |
| Reimbursement of fees above the rate eligible for the allowance | yes, up to the sum insured | „Der Tarif Genau-Für-Sie Ergänzung übernimmt die verbleibenden Kosten nach Vorleistung …“ | B. Was ist versichert, page 2 |
| Extra costs abroad above the domestic allowance rates | yes, up to the sum insured | „Bei Behandlungen im Ausland erstatten wir die Gebühren im tariflichen Umfang auch über …“ | B. Hinweis, page 2 |
| Cover abroad for temporary stays (duration, worldwide or Europe) | yes | „Bei einem Auslandsaufenthalt im außereuropäischen Ausland besteht zeitlich unbegrenzter …“ | D. 1, page 4 |
| Repatriation from abroad | not addressed |
Trainees, admission and waiting periods
| Point | Rule | Wording (German) | Clause |
|---|---|---|---|
| Trainee tariff with reduced premium (without or with low ageing reserves) | not addressed | ||
| Maximum age or duration for the trainee tariff | not addressed | ||
| Conversion to the regular tariff after training without new health check | not addressed | ||
| General waiting period | not addressed | ||
| Special waiting periods (childbirth, psychotherapy, dentures, orthodontics) | yes | „Versicherungsschutz besteht nach Ablauf von zwei Jahren - gerechnet vom …“ | B. 1 b), page 3 |
| Waiver of waiting periods (transfer from statutory insurance, appointment as civil servant, medical exam) | not addressed | ||
| Cover for newborns without health check and waiting period | not addressed | ||
| Exclusion or surcharge for pre existing conditions | not addressed |
Contract and premium
| Point | Rule | Wording (German) | Clause |
|---|---|---|---|
| Annual deductible per insured person | not addressed | ||
| Premium refund for claim free years (monthly premiums, guaranteed or performance based) | not addressed | ||
| Check ups and dental prophylaxis without loss of the premium refund | yes | „Wenn Sie zahnmedizinische Prophylaxe-Maßnahmen nutzen, wirkt sich das nicht auf den …“ | B. 2 b), page 3 |
| Dormant cover (free medical care, service abroad, leave, parental leave) | not addressed | ||
| Insurer waives ordinary termination | not addressed | ||
| Continuation as full cover at 100 per cent on leaving the civil service | no | „endet mit dem Fortfall der Beihilfeberechtigung bzw. der Berücksichtigungsfähigkeit bei …“ | D. 5 a), page 5 |
| Premium adjustment rules (triggering factor) | not addressed | ||
| Direct billing with the hospital | not addressed |
Austria and Spain
| Point | Rule | Wording (German) | Clause |
|---|---|---|---|
| Group tariff for public servants for private ward cover alongside the statutory scheme | not addressed | ||
| Reimbursement of the statutory treatment contribution | not addressed | ||
| Insurer under agreement with MUFACE, ISFAS or MUGEJU (term of the agreement) | not addressed | ||
| Provider catalogue (doctors and clinics per province, care levels by municipality size) | not addressed | ||
| Change of insurer or to the public system (ordinary change windows per year) | not addressed | ||
| Treatment outside the catalogue (life threatening emergency, refused service) | not addressed | ||
| Care through the public system in rural municipalities | not addressed |
Evaluated by NAMMERT from published policy wordings.
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Policy wordings and provider
- Legal entity
- Gothaer Krankenversicherung Aktiengesellschaft
- Distribution
- brokers and direct
- Tarif Genau-Für-Sie Ergänzung, Ergänzungstarif für Personen mit Anspruch auf Beihilfe (Teil III, K 5255) Edition: Stand 01.07.2022 (K 5255 0722) Original from the insurer (PDF, German)
Full text of the wording
The full text exists only in German.
It is printed on the German page for Gothaer BarmeniaGothaer Beihilfeergänzung Genau-Für-Sie
Ergänzung and available as plain text.
Volltext Gothaer BarmeniaGothaer Beihilfeergänzung Genau-Für-Sie Ergänzung Beihilfeversicherung · As text (Markdown) Gothaer BarmeniaGothaer Beihilfeergänzung Genau-Für-Sie Ergänzung Beihilfe cover