Gesundheitsprüfung

What the assessment actually is

The Gesundheitsprüfung is the insurer's decision-making process for a PKV application. There is no physical exam. It is a written health questionnaire, the Gesundheitsfragebogen, combined with your signed consent allowing the insurer to request medical records from doctors you have seen.

Typical questions cover the previous 3-10 years, depending on the item. Short-lookback topics (colds, minor sprains) are usually 3-5 years; long-lookback topics (hospital stays, chronic conditions, psychotherapy, back problems) can reach 10 years. Mental-health questions are almost always 5-10 years. A few items, HIV, malignant cancer, addiction history, are asked lifetime by most insurers.

The four possible outcomes

An application produces one of four results:

• Normal acceptance, the premium is what the tariff calculates for your age and coverage, no adjustment

• Risk surcharge (Risikozuschlag), an additional percentage is added to the premium to reflect a specific condition

• Benefit exclusion, a specific condition is explicitly removed from coverage (e.g. "all treatments related to a specific pre-existing diagnosis")

• Rejection, the insurer declines to accept

A common misread: acceptance with a surcharge is a perfectly normal outcome, not a "failure". Many applicants with mild chronic conditions (hypertension, mild back issues, historic depression that is fully resolved) go through with manageable surcharges.

Risikovoranfrage: the key tool

The Risikovoranfrage (risk pre-enquiry) lets you test the market without a formal application. Your broker anonymises your details (year of birth only, no name), lays out your medical history, and asks three to five insurers what they would do with the profile.

Responses come back as one of the four outcomes above, so you know, before filing anything, which insurers will accept you cleanly, which will surcharge you, and which will reject. Crucially, the Risikovoranfrage does not create any formal record at the insurer that could affect a later application. Cross-insurer risk databases like HIS (Hinweis- und Informationssystem) are used in life and disability insurance, not in PKV underwriting, so you can compare freely without fear of being flagged.

This is the single most powerful tool if you have any meaningful medical history. A formal application that gets rejected creates a record that can complicate future applications elsewhere.

Before you fill out the questionnaire

Two pieces of preparation materially change the quality of your answers:

• Request your medical records from your GP. German patients have the right to a free copy under § 630g BGB. The file is the benchmark against which the insurer later checks your answers if a claim triggers a review.

• Prepare a dated timeline. "Once had back pain around 2019, resolved quickly" is the kind of vague memory that causes Anzeigepflicht problems later. "Three physio sessions between March and April 2019, no recurrence since" is what the form actually wants.

Lifetime questions: HIV, cancer, addiction

A few diagnoses break the standard 3-10 year window: HIV, malignant tumours, and addiction history are asked for life ("jemals") at most insurers, regardless of how long ago. If any of these sit in your medical record, the Risikovoranfrage matters even more than usual. Different insurers handle the same lifetime-history profile very differently, and a broker survey of the market is the only way to see which one offers the best route.

Disclosure: what happens if you get it wrong

The legal framework is § 19 VVG (duty of pre-contractual disclosure) and the consequences are severe. If the insurer later finds that you failed to disclose a relevant condition, the options available to them depend on the degree of fault:

• Simple negligence: one-month cancellation right only

• Gross negligence: right to withdraw from the contract, or to retroactively adjust it

• Intent: withdrawal with no premium refund for the period

• Fraudulent intent (Arglist): contract voidable under § 22 VVG + § 123 BGB, services already paid can be clawed back

The insurer's rights expire 5 years after contract start for ordinary faults, 10 years for intentional or fraudulent breaches. Insurance cases that occurred before the deadline can still be refused after it.

Two practical rules that follow from this:

• Never omit a condition hoping it will "slip through". The data request to your GP will find it, usually at the moment you first try to claim for something related.

• If you are unsure whether something qualifies, disclose it in detail and let the insurer's medical unit decide. Over-disclosure creates no problem. Under-disclosure creates contract risk.