Gender reassignment surgery: What if the health insurance company gets in the way?

Anyone who has decided to have gender reassignment surgery will comparatively quickly face the question of whether the corresponding costs will be covered by the statutory health insurance. Basically, it is necessary to apply for many services, such as psychotherapy and for the assumption of costs in connection with various aids and operations.

Those who are unsure about how much of a financial burden the trans person in question will face should not hesitate to ask either at a public counseling center or directly at the health insurance company.

Some treatments, such as special hormone therapies, usually do not require a separate application.

Applicants are well advised to document all correspondence with the health insurance company and to allow sufficient time for the application. The fewer questions that need to be asked, the shorter the decision-making process usually is.

When the Medical Service is called in...

In many cases, the health insurance company switches on the Medical service to get a better, more detailed picture of the situation in question.

When an expert opinion is drawn up, the relevant transpersons have the opportunity (and the right) to inspect it. Therefore, it is always useful to request the respective documents for yourself and your personal filing system. These provide a good basis, for example, when it comes to being able to counter a possible contradiction in a well-founded manner.

If the health insurance fund does not agree and does not uphold the applicant's objection, the applicant can file a complaint. Depending on the case, it may also be worth filing a complaint with the relevant supervisory authority.

Anyone who feels overwhelmed by this should consult a lawyer at an early stage. Many experts have specialized in this area and are therefore able to reliably represent their clients.

Application: What role do deadlines play?

Health insurance companies must not take "forever" to approve or reject the corresponding application. Applicants should be informed of the decision after five weeks at the latest. If there is no reason for the health insurance fund to take longer, the application is usually considered approved.

Please note: If the medical service is called in, it is of course legitimate that the whole thing takes longer. Therefore, it is always important to examine and evaluate the individual case.

Gender reassignment: how a contradiction goes

If the health insurance company refuses to cover the services, the applicants have the opportunity to file an objection free of charge (within one month and in writing). After that, everything will be reviewed again.

The easiest way is to keep the objection short at first, then short-circuit with the treating physicians and then justify it in more detail. It is important not to let the deadline pass. After that, there is still time to elaborate your own position in more detail. If necessary - as mentioned above - it may also be useful to work with a lawyer.

After the responsible health insurance company receives the objection, it has three months to respond.

It is advisable to file a lawsuit against the objection if the rejection violated the law. The proceedings that may arise from this can be very lengthy.

Additional tip: Perhaps the problem also lies in the assessment of the medical service? In this case, it might be worth filing a complaint with the MDK before filing a lawsuit.

Conclusion and support for those affected

Ideally, the application for the corresponding benefits at the health insurance company is of course completely uncomplicated. However, experience shows that there may well be rejections. Anyone who is affected, but at the same time earns too little to be able to afford a (possibly costly) lawsuit, can apply for legal aid and/or legal aid.

The former applies to legal advice or support away from the court, for example when it comes to appealing against a rejection. If the whole thing goes a step further, legal aid becomes topical. This refers to legal support during the court proceedings. The application for this is made directly to the court.

The good news, however, is that cooperation with the relevant health insurers is often less complicated than initially feared. Nevertheless, it is of course always useful to have a "Plan B" up your sleeve.