Application refused: how to lodge an objection with your health insurance fund

Key facts at a glance

• You have one month to object to a decision – counted from receipt, not from the date of the letter
• The objection costs nothing and initially needs no reasons: meet the deadline, submit the reasons later
• You have a right of access to the file – ask for the assessment on which the refusal is based
• The fund must either remedy the matter or issue an objection decision; after that there is one month for court action
• If the fund does not decide within three weeks (five with an expert opinion), the benefit is deemed approved – with an important limitation

A refusal notice sounds final. It is not. Social law provides a regulated, free-of-charge way to have a decision reviewed – and a considerable proportion of objections succeed because the fund's reasoning does not hold up in the individual case. This article goes through the path step by step.

Step 1: Meet the deadline

Section 84 (1) of the Social Courts Act (SGG):

“The objection must be lodged within one month after the administrative act has been notified to the aggrieved party, in writing, in electronic form […] or for the record with the body that issued the administrative act.”

Three things follow:

• One month from notification – i.e. from the day the letter arrived. Note the date on the envelope.
• In writing or for the record – a letter is enough, as is appearing in person at the branch office, where the objection is recorded. A plain email usually does not meet the formal requirement; many funds offer an online mailbox for this.
• With the body that decided – i.e. with your health insurance fund itself.

The law does not require reasons at this point. Two sentences are enough to meet the deadline:

“I hereby object to your decision of [date], reference [file number]. I will submit the reasons later. Please grant me access to the file, in particular to the underlying assessment.”

And it costs nothing: under Section 64 (1) SGB X, “no fees and expenses are charged” for proceedings before the social authorities.

Step 2: Inspect the file

Section 25 (1) SGB X obliges the authority “to allow the parties to inspect the files relating to the proceedings insofar as knowledge of them is necessary to assert or defend their legal interests”. With a refused medical aid, this is always the case.

What is interesting here is who reviewed the case. Section 33 (5b) SGB V requires the fund to review applications for medical aids “with its own staff bound by instructions”; it may involve the Medical Service “in suitable cases”, third parties not at all. If the file contains no medical assessment but only a case worker's note, this is a starting point: a medical assessment from your doctor then carries more weight than what the fund had before it.

Step 3: The reasons

Refusals of medical aids are almost always based on one of three phrases: “not necessary”, “not economical” or “quantity not comprehensible”. The reasons start exactly there.

• Necessity is the standard of Section 33 (1) SGB V: the medical aid must be “necessary in the individual case” to ensure the success of treatment, prevent a disability or compensate for it. Have your doctor write a statement that relates exactly these three points to your case – not repeating the diagnosis but explaining what happens without the aid.
• Quantity: keep a record – for incontinence, of consumption and reasons for changing; for catheterisation, of frequency and volumes. The clinical guideline on intermittent catheterisation expressly states that material is to be provided “in sufficient quantity” and that a limitation “for economic reasons” should not take place. Such sentences belong in the objection – verbatim, with the source.
• Everyday life: what works with the aid, what without? Specifically, in situations, not in adjectives. Family members and the care service can confirm this in writing.

Step 4: What the fund must do now

Section 85 SGG leaves it two ways: “If the objection is considered justified, it shall be remedied.” Otherwise an objection decision is issued – in social insurance by a body determined by the assembly of representatives, in practice the objection committee, on which insured persons' representatives also sit. This is a different body from the case handling that first refused.

If the fund takes its time, Section 88 SGG helps: if an objection has not been decided within a reasonable period without sufficient reason, court action can be brought – after three months for an objection, after six for an initial application.

Step 5: Court action

If the answer remains no, a new deadline begins with the objection decision: Section 87 SGG gives one month to bring an action before the social court. Whether this is worthwhile should be discussed in a consultation – with a social association, a lawyer specialising in social law or the Independent Patient Advice Service.

Deemed approval – and what the Federal Social Court made of it

Section 13 (3a) SGB V sets deadlines for the fund: three weeks from receipt of the application, five weeks if an expert opinion is obtained. If it cannot meet the deadline, it must notify this “in good time in writing or electronically, stating the reasons”. And then the sentence that has made it into many guides:

“If no sufficient reason is communicated, the benefit is deemed approved after expiry of the deadline.”

Caution is required here. On 26 May 2020 (B 1 KR 9/18 R), the Federal Social Court abandoned its earlier case law: deemed approval does not establish an independent entitlement to the benefit in kind. It only leads to a claim for reimbursement of costs – under Section 13 (3a) sentence 7, for a “necessary” benefit that one has obtained oneself after expiry of the deadline.

In practice this means: if the deadline passes without notice, you can buy the medical aid yourself and reclaim the costs. But you pay in advance, and the fund can still dispute whether the benefit was “necessary”. Anyone taking this route should have the necessity medically documented – and the deadline recorded.

When it is about the care level

The same one-month deadline applies to decisions of the long-term care insurance fund. Here, access to the file is particularly valuable: the assessment report is enclosed with the decision anyway, and it contains a tick for each criterion under “independent”, “largely independent”, “largely dependent” or “dependent”. Every tick that does not match everyday life is a ground for objection. How the assessment works is explained in our article on the care level.

Frequently asked questions

Can the objection harm me?

No. It costs nothing, and the fund may not withdraw a benefit already granted because you are challenging another decision.

The deadline is almost up and I do not have any documents yet.

Lodge the objection anyway – two sentences, reasons to follow. The deadline applies to the objection, not to its reasons.

Can my supplier lodge the objection for me?

Only with a written power of attorney. But it can support you with documents – proof of consumption, product information, medical aid numbers.

Do I have to go to the fund in person?

No. A letter by post is enough. Anyone who wants to be sure hands it in at the branch office and has receipt confirmed.

Who helps me free of charge?

The Independent Patient Advice Service Germany (UPD), social associations such as VdK or SoVD (membership required), care support points and the consumer advice centres. For complex cases, a lawyer specialising in social law is worthwhile.

Your next step

If a prescription you submitted to us is refused, we put together the documents you need for the objection: medical aid numbers, product descriptions, consumption overviews.

Sources

• Section 84 SGG – objection period, Section 85 – remedy and objection decision, Section 87 – period for court action, Section 88 – action for failure to act, Federal Ministry of Justice (in German)
• Section 25 SGB X – access to files, Section 64 SGB X – exemption from costs
• Section 13 SGB V – decision deadlines, deemed approval, Section 33 SGB V – medical aids
• Federal Social Court, judgment of 26 May 2020, B 1 KR 9/18 R (in German)
• S2k guideline “Management and performance of intermittent catheterisation”, AWMF 043-048, version February 2026 (in German)