The deadline is calculated precisely to the day; for example, if the application is received by the health insurance company on March 4, 2016, the 3-week deadline expires on March 25, 2016. A decision on the application must then be available no later than March 25, 2016.

The aforementioned deadline also applies if, for example, the aid in question serves the purposes of both health and long-term care insurance, as can be the case with bath lifts. The legislator has created an explicit regulation for this in Section 40 Paragraph 5 of the German Social Code, Book XI (SGB XI). When an application for such an aid, like the bath lift mentioned above, is received by the health insurance fund, the health insurance fund must make a decision on the application. Since it is an application to the health insurance fund, the aforementioned deadlines also apply. Whether a settlement is to be made between the health and long-term care insurance funds is solely a matter of their internal relationship and does not affect the decision deadline. Should deadlines not be met, the insured person must be informed in writing within the deadline. "In a timely manner" in this context means that the health insurance fund must inform the insured person as soon as it realizes that a decision cannot be made within the deadlines. Since the legislator explicitly requires written notification, information by email is insufficient.

Proper investigations

The written notification must then explain the sufficient reason for exceeding the deadline. A sufficient reason exists whenever the health insurance company needs to conduct proper investigations. These proper investigations must be carried out with due diligence. Investigations are considered proper when they serve to clarify factual questions relevant to the decision regarding the claim. Therefore, clarifying legal questions is not considered a proper investigation. Answering purely legal questions does not require any investigations, such as contacting the treating physician. If the health insurance company relies on a sufficient reason, it must explain the proper investigations conducted.

Situations arising from the organization of the health insurance fund, such as staff shortages during vacation periods, are not sufficient grounds for an extension. An authority must be organized in such a way that even these recurring situations can be handled within the legally prescribed time limits.

The burden of proof for the existence of sufficient grounds lies with the health insurance company. In the event of a dispute, it must present and, if necessary, prove all relevant circumstances.

If the health insurance company violates the above regulations because it has not provided the insured person with a sufficient written explanation within the deadlines, two legal consequences will occur:

• The service is considered approved, specifically as requested.
• and the insured person can obtain the requested service himself after the deadline has expired and have the costs incurred reimbursed by his health insurance fund.

The so-called deemed approval and the reimbursement of costs are two different legal consequences, which are therefore presented separately below:

1. Deemed Approval

The deemed approval provision is not unique to the new regulations. Rather, deemed approval provisions can be found in the German Social Code, Book V (SGB V), and other legal regulations. For example, consider the application for therapeutic treatments such as physiotherapy. In this area, decisions on long-term prescriptions must be made within four weeks; otherwise, approval is deemed granted after this period. A deemed approval provision always means that the law assumes a specific administrative act has been issued by the authority/health insurance fund. It thus presumes the effective notification of approval.

2. Reimbursement of costs

In addition to the deemed approval and the associated entitlement to benefits in kind, the legislator has granted the insured another option for enforcing their claim. The insured can procure the necessary service themselves and then bill their health insurance company. This requires a private agreement between the service provider and the insured regarding the procurement of the specific assistive device. The insured then submits the invoice to their health insurance company. Since the legislator explicitly refers to the reimbursement of incurred costs, the health insurance company cannot refer to contract prices or fixed amounts for this private invoice. These only apply in relation to the service provider.,
However, this does not apply to private invoices within the framework of cost reimbursement. This has already been clarified by the courts in the context of other cost reimbursement claims under statutory health insurance. For example: A contract exists between the health insurance fund and the service provider regarding the reuse of an assistive device owned by the health insurance fund. The contract and its prices do not affect the insured person's right to cost reimbursement. Rather, the service provider may not sell the health insurance fund's property to the insured person by way of a private agreement. The service provider can only sell an assistive device that is their own property to the insured person. And this purchase price must be reimbursed by the health insurance fund. These expedited regulations apply to all applications submitted from February 26, 2013, the date of entry into force. With the new Section 13 Paragraph 3a of the German Social Code, Book V (SGB V), the legislator has significantly strengthened the rights of insured persons when applying for benefits. The Federal Social Court (BSG), in its judgment of March 8, 2016 (Case No. B 1 KR 25/15 R), confirmed the effect of the deemed approval provision of Section 13 Paragraph 3a of the German Social Code, Book V (SGB V), in cases where a health insurance fund misses a deadline. The case concerned a claim for reimbursement of costs for psychodynamic psychotherapy. The defendant health insurance fund obtained an expert opinion but failed to inform the plaintiff. Based on the expert opinion, the fund rejected the application for benefits almost six weeks after receiving the application. The BSG has now ruled that the benefit is deemed approved because the health insurance fund failed to decide on the application within three weeks without providing reasons. The plaintiff could also subjectively assume the necessity of the benefit, as it was not obviously a service outside the scope of services covered by statutory health insurance, and his therapist had provided a corresponding assessment. Since the plaintiff obtained the benefit himself in the meantime, he was entitled to reimbursement of his costs from his health insurance fund.