Risikozuschlag

What is a Risikozuschlag?

A Risikozuschlag is an additional percentage charged by a PKV insurer on top of the normal tariff premium, to reflect the added statistical risk of a specific pre-existing condition. It is the insurer's way of accepting someone they would otherwise reject, you get access to the coverage, they get compensated for the heightened claim expectation.

The surcharge is applied at underwriting and typically stays for the life of the contract, though some surcharges can be reviewed and removed after a defined period if the underlying condition has been permanently resolved.

How it is calculated

Each insurer keeps internal actuarial guidelines mapping conditions to surcharge ranges. The factors that move a surcharge up or down:

• Severity, mild well-controlled hypertension is different from uncontrolled severe hypertension

• Treatment history, diagnosed but untreated vs. actively managed with medication

• Time since diagnosis, a condition fully resolved five years ago is treated differently from one ongoing

• Comorbidities, multiple conditions compound the assessment

Typical Risikozuschlag ranges in the market:

• Mild, resolved, historic conditions: 0 % (normal acceptance)

• Moderate, well-managed conditions: 10-25 % surcharge

• Significant or unstable conditions: 30-50 % surcharge, or benefit exclusion

• Severe or unstable conditions: rejection or only the Basistarif remains available

These are ranges, not rules. The exact percentage depends heavily on the insurer's internal guidelines, which differ substantially.

The wide spread between insurers

For the same condition, one insurer might apply a 0 % surcharge while another applies 30 %. Real examples from broker experience:

• A historic episode of depression (resolved 6+ years ago, no medication since): accepted at 0 % by some insurers, 10-15 % surcharge at others, excluded outright by a few

• Mild controlled hypertension: 0-15 % depending on insurer

• A resolved back injury with physio history: typically 0-10 %, occasionally 20 %

This variation is why a Risikovoranfrage (anonymised risk pre-enquiry) is so valuable for anyone with medical history. Running the same profile past 3-5 insurers can produce a €30-€100/month difference in lifetime premium for the same cover.

The four possible outcomes

A PKV application produces one of four decisions:

• Normal acceptance, no surcharge, no exclusion

• Risikozuschlag, surcharge added, full cover otherwise

• Benefit exclusion (Leistungsausschluss), specific condition removed from cover, no surcharge. Appropriate when the condition is well-bounded and unlikely to affect other care

• Rejection, decline to accept

The middle two are trade-offs with different long-term consequences:

• Surcharge: you pay more, but you are covered if the condition comes back

• Exclusion: you pay nothing extra, but you lose cover for anything linked to the excluded diagnosis

Which is better depends on profile. A resolved condition with low recurrence risk often pairs better with a surcharge (cheaper if it stays resolved, protected if it does not). A niche condition that is unlikely to need active treatment often pairs better with an exclusion.

When a surcharge can be removed

Some surcharges are reviewable, the AVB (Allgemeine Versicherungsbedingungen, the general policy terms) or the insurer's internal rules allow reassessment after a defined period (typically 2-5 years). If the condition has been permanently stable, the surcharge can be removed in full or part. This usually requires:

• A formal request to the insurer

• Current medical evidence (GP letter, recent examination)

• Documented absence of treatment for the defined period

Not every surcharge is reviewable. Many stick for the life of the contract regardless of how the condition evolves. The reviewability is contract-specific, worth confirming at signup, not assuming.

The Öffnungsaktion cap

For civil servants (Beamte) and candidates (Anwärter) with pre-existing conditions, the PKV industry offers the Öffnungsaktion, a voluntary industry agreement that caps surcharges at 30 % when applied within 6 months of appointment. Outside that window, normal underwriting rules apply with no cap.

See the Beamte entry for the full context.

Why disclosure still matters

A surcharge is not a penalty, it is the insurer's route to accepting you. The penalty is what happens if you try to hide a condition to avoid the surcharge. Under § 19 VVG, the insurer can unwind the contract years later when a related claim surfaces. A clean acceptance at 0 % that was built on an omission is far more dangerous than a transparent acceptance at 15 %.

See the Gesundheitsprüfung and Vorvertragliche Anzeigepflicht entries for the disclosure framework.