Reservation

What is a reservation?

A reservation (Vorbehalt) is a clause in your insurance contract with which the insurer excludes a specific health risk from cover. You are insured, but the insurance pays nothing for the illness named, its consequences or a specific part of the body. Typical reservations concern back problems, knees, allergies or a previous operation.

Reservations only exist where the insurer would be allowed to turn you down. This is the case in supplementary insurance, which is governed by the Insurance Contract Act (ICA, VVG in German). Instead of turning you down completely, the insurer offers you the contract with a restriction. Reservations are also permitted in voluntary daily allowance insurance under the Federal Health Insurance Act (KVG), but with a statutory maximum duration.

There are no reservations in basic health insurance. Every insurer must accept every person required to take out insurance within its area of operation, regardless of age and health. It asks no health questions and may not exclude any illness.

How it works

When you apply for supplementary insurance, you fill in a health questionnaire. The insurer checks your answers and then decides in one of three ways:

1. Acceptance without restriction. You are insured for all the benefits of the product.
2. Acceptance with a reservation. The insurer excludes one or more illnesses, either for a limited period or indefinitely. The clause is set out in the policy.
3. Rejection. The insurer does not have to accept you for supplementary insurance.

A reservation only applies to what it states. If you have a reservation for your left knee and break your arm, the supplementary insurance pays as normal. You pay for treatment of the condition covered by the reservation yourself or, to the extent it is covered, through basic health insurance. The reservation therefore only affects supplementary benefits, such as the semi-private ward in hospital or supplementary outpatient benefits.

Stricter rules apply in daily allowance insurance under the KVG: the reservation lapses after 5 years at the latest and is only valid if the insurer notifies it in writing and states the illness and the start and end precisely. If you switch insurer because you change jobs, the new insurer may not impose any new reservations.

Legal basis

For basic health insurance, Art. 5 let. i of the Health Insurance Supervision Act (KVAG) requires an insurer to accept every person required to take out insurance within its local area of operation. For daily allowance insurance under the KVG, Art. 69 para. 1 KVG allows reservations for existing illnesses and previous illnesses likely to recur; para. 2 limits them to a maximum of 5 years, and para. 3 requires written notification stating the illness, the start and the end. Art. 70 para. 1 KVG prohibits new reservations when switching for certain reasons, for example because of the employment relationship.

For supplementary insurance, the ICA contains no specific rule on reservations; reservations are part of the contract. Art. 4 ICA requires you to answer the questions in the application truthfully. Art. 6 ICA allows the insurer to terminate the contract within 4 weeks of finding out if you breach this duty. Under Art. 35a para. 4 ICA, only you, not the insurer, have the ordinary right to terminate supplementary health insurance. A contract once concluded without a reservation therefore remains in place even if you later fall ill.

Example: supplementary hospital insurance with a knee reservation

Nina, 38, applies for semi-private supplementary hospital insurance. In the questionnaire, she states that she had an operation on her right knee two years ago. The insurer accepts her, with an indefinite reservation for the right knee.

What this means for you

• Answer the health questionnaire completely. A reservation is almost always better than a contract that later falls away because of a breach of the duty of disclosure.
• Read the reservation clause carefully. Does it name a diagnosis, a part of the body or “consequences of”? Is it limited in time? Ask if the wording is unclear.
• Do not cancel existing supplementary insurance too hastily. An old contract without a reservation is often worth more than a new one with a reservation. You can switch basic health insurance and supplementary insurance separately.
• Compare basic health insurance freely. Because there are no reservations there, you can choose any insurer. The premium calculator shows the premiums, and you will find information on the insurers under health insurers. The deadlines for switching are listed under deadlines.

Common mistakes

• Believing that basic health insurance can also impose reservations. It may not. Every insurer must accept you.
• Concealing illnesses to avoid a reservation. This can cost you the entire contract.
• Cancelling both types of insurance at the same time. If you give up supplementary insurance before the new one is confirmed, you risk reservations or a rejection.
• Forgetting the reservation. For treatment of the condition covered by the reservation, only basic health insurance pays. Plan the costs accordingly.

We explain how we compare supplementary insurance under How we calculate.