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Like all elements of your German private health insurance policy, the details surrounding conditions for choosing a doctor need to be carefully considered. This especially applies for the Family Doctor Principle. As with anything, there are advantages and disadvantages to the model. There are also varying degrees of flexibility and benefits available, depending on the type of coverage you’ve selected.

Decisions surrounding your freedom to choose a doctor is not as easy as simply checking a box. You should always speak to your health insurance broker and read the terms of your insurance policy properly first.

The Family Doctor Principle also exists as a term for statutory health insurance. But, for the purpose of this blog post, we specifically discuss the Family Doctor Principle in the context of private health insurance and here it is related to outpatient treatment.

What is the Family Doctor Principle?

To put it simply, the family doctor (or Facharzt für Allgemeinmedizin, Hausarzt) is the term for your general practitioner or GP. This is simply because it is common to see the same doctor each time you require medical assistance so that your doctor has knowledge of your medical history. Of course, this shouldn’t come as a surprise to most expats and is conventional in many countries around the world.

The Family Doctor Principle is also commonly referred to as the General Practitioner Model OR Primary Physician Model. AXA was the first insurance company to establish it in the 1980s. AXA sought to create a more inexpensive and simpler model for their policy holders. Pioneering the Family Doctor Principle meant that doctors could act somewhat like a ‘gate-keeper’ for more specialist medical treatments. It meant that everyone had to see a family doctor or GP before being treated by a specialist. Private health insurance in Germany was associated with freedom in the choice of doctor until that time. This also included the privilege of being able to visit specialists directly without referral from the family doctor.

Ultimately, the Family Doctor Principle would help avoid double treatments and patients going directly to specialists when it wasn’t necessary. This would streamline the system, keep costs down and make health insurance plans cheaper. Sounds great, right? Yes, but there is a lot to consider when it comes to the rules surrounding the Family Doctor Principle within your individual policy. Every health insurance provider and plan offers a different level of coverage.

How Does the Family Doctor Principle Work

The general basis of the Family Doctor Principle means that your private health insurer will pay 100% of your outpatient medical care. This is provided you follow their terms surrounding the Family Doctor Principle. Generally, this requires you to see a family doctor or GP for your condition or medical concern first. You would then seek the treatment of a specialist (be that a dermatologist, cardiologist, neurologist and so on) only after initial consultation or referral from a family doctor.

Many private health insurance plans stipulate that non-compliance with this process means that the insurer will only pay up to 75-80% of your treatment. This leaves you to pay the rest. Doesn’t seem like a major issue? What if you’ve skipped the initial family doctor visit and are diagnosed with a long-term chronic illness or disease? You would be 25% out of pocket for every treatment, follow up or medicine required for that illness for the rest of your life. That sounds like a pretty big financial burden if you ask us!

With stricter health insurance plans, many people suffer the consequences of this by not fully understanding the Family Doctor Principle. Other private health insurance companies are a little more generous. They may provide a loophole that allows you to go back and visit a family doctor if you find yourself in this situation. But be careful- this is not always the case!

 
 
 

What to Look for In Your Health Insurance Policy

When it comes to the Family Doctor Principle within your individual health insurance policy, we highly advise you speak directly with your insurance broker or speak to your health insurance provider to get clarity on the details that affect you. The level of flexibility offered is the important thing to understand.

From our years of experience working with a range of different policies when it comes to the Family Doctor Principle, we’ve identified that there are generally four tiers of flexibility offered:

Low-tier: cheaper and basic health insurance plans tend to offer a much stricter model when it comes to the Family Doctor Principle. For example, most require you to provide the specific name of the family doctor you intend to see throughout the lifetime of your policy. If you wish to change your family doctor, you would need to apply to do so. Similarly, if your doctor is on holiday or ill, this may also be an issue

Mid-tier: some health insurance plans offer what is called the Primary Physician Model. This model stipulates that you can see any family doctor or GP that you like, provided that you still do so before seeing a specialist

High-tier: these plans offer the most flexibility. They are often more expensive but they include all the benefits of quality Family Doctor Principle coverage. This includes anything from having three family doctors to choose from (so you don’t need to visit the same doctor each time)

Complete ‘free choice of doctors’: this is the counterpart to the Family Doctor Principle. It waves the need to see a family doctor for a specialist’s referral altogether. These are the most comfortable rates, that give the customer the greatest possible freedom when choosing a doctor. Certainly those private health insurance plans are a bit more expensive.

Why You’re Better off With ‘Free Choice of Doctors’

Still not particularly phased by making sure you have adequate Family Doctor Principle coverage? Here are some of the pitfalls you may experience if you opt for a stricter policy:

Long-term impact: it won’t only be your initial specialist treatment that’s not covered if you don’t follow the terms of your health insurance’s Family Doctor Principle. It will be all treatments related to that injury or condition as well as all medication prescribed.

Convenience: you may want flexibility in your Family Doctor Principle due to your lifestyle. For instance, if you travel a lot or have a high-pressure job that doesn’t allow for a lot of time spent in doctor’s waiting rooms, you may want the flexibility to be able to go to specialists direct, rather than going to a family doctor first. This also applies to the elderly or disabled who are dependent on others to physically take them to a doctor’s appointment.

Make an informed choice: as always, you should think carefully about your health insurance plan. Changes or upgrades aren’t always straightforward. If you’ve already locked yours in, most providers offer the ability to update your contract after 3-4 years. This can be done without the hassle of red tape or another medical assessment. If you’ve had your insurance plan for up to two years, it’s time you reviewed your policy to ensure it’s right for you. Feel free to get in touch with KLForExpats. We can help!

Doctor status: your family doctor or GP may be technically classified as a internal medicine physician or a specialist who is operating as a GP as well. Do you have strict Family Doctor Principle terms in your policy? Always double check with your insurance provider that your doctor is recognised as a family doctor or GP

 

Exceptions to the Family Doctor Principle

It’s important to ALWAYS read the fine print, as with all matters related to German private health insurance . However, general widely recognised exceptions include:

The Family Doctor Principle generally does not apply to treatments required whilst abroad

 

 

 

Some specialists do not fall under The Family Doctor Principle. Therefore, do not require you to see a family doctor to obtain a referral first. Such specialists include ophthalmologists, gynaecologists and paediatricians

You can to visit an emergency doctor or a specialist doctor on call if you have an emergency

 

 

At the end of the day, there is no ‘good or bad’ when it comes to what you choose. You either buy cheap private health insurance which includes the Family Doctor Principle… Or you pay a little more if you want to enjoy a free choice of doctor. The right choice is dictated by your needs. And don’t forget to always read the fine print so that you don’t get caught out paying unnecessary medical bills.

Still have questions about the Family Doctor Principle?

Mirja Link-Lundehn

Get in touch with KLforExpats for an obligation-free chat to discuss your private health insurance options.

We answer promptly.

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