In Germany, hip and knee replacement surgeries are common procedures for restoring mobility and quality of life in patients with advanced joint diseases. While such interventions are traditionally performed in public hospitals, more and more patients are considering treatment in private clinics. However, a common misconception is that private clinics are reserved exclusively for private patients. In fact, statutory insured individuals can also benefit from the services of a private clinic under certain conditions, particularly through the single cost reimbursement procedure.

In this comprehensive guide, we will explain in detail the concept of individual cost coverage, describe the process of applying to statutory health insurance funds for hip and knee replacement surgeries in private clinics, and show how patients like you can take advantage of this option.

What is individual cost coverage?

The individual cost reimbursement is a procedure in which the statutory health insurance covers the costs for medical treatment in a facility that does not have a contractual agreement with the statutory health insurance, as is often the case with private clinics. This means that the health insurance covers the treatment costs in the private clinic up to the amount that would have been incurred in a public hospital. Any additional costs must be borne by the patient themselves.

This procedure allows statutory insured individuals to receive services that may not be included in their regular service catalog or are provided in facilities that are not part of the standard network of statutory health insurance.

Requirements for individual cost coverage for hip and knee prostheses

To receive a single cost coverage for a hip or knee replacement surgery in a private clinic, certain prerequisites must be met:

1. Cost Neutrality
2. Medical necessity: The surgery must be medically necessary and comply with the guidelines of the statutory health insurance.
3. Lack of Treatment Options
4. Prior Approval

The application for individual cost coverage: Step-by-step guide

The process of applying for a single cost coverage may seem complex, but with the right preparation and procedure, you can increase your chances of approval. Here is a detailed guide:

1. Consultation with the treating physician
2. Obtain a cost estimate: Request a detailed cost estimate from the private clinic, listing all expected treatment costs. This should be comparable to the usual costs in public hospitals.
3. Submit application to health insurance: Submit the cost estimate along with a formless application for cost coverage to your statutory health insurance. Justify why the treatment should be done in the private clinic and attach all relevant medical documents.
4. Waiting time and inquiries
5. Wait for approval: Start treatment only after receiving written approval from your health insurance fund. Without this approval, you bear the financial risk yourself.

Benefits of Treatment in a Private Clinic

The decision to undergo treatment in a private clinic offers several potential benefits:

• Individual care: Due to a lower number of patients, private clinics can often provide more personal and intensive care.
• Specialization: Many private clinics specialize in specific areas and have experienced specialists, which can lead to better treatment outcomes.
• Comfort and equipment: Private clinics often offer upscale equipment and additional comfort, such as single rooms or special services.
• Flexibility with appointments: Due to a more streamlined organization, shorter waiting times and more flexible appointment scheduling can often be achieved.



Common misconceptions and clarifications

There are some common misconceptions regarding the treatment of statutory insured individuals in private clinics:

• Myth: Private clinics are only for private patients
• Myth: High additional costs for statutory insured persons
• Myth: Complicated application process: With proper preparation and support from the treating physician, the application process is manageable and easy to handle.