Take advantage of our free initial consultation with a health insurance law specialist in your area.
Why should you mandate your attorney when we can refer you to expert attorneys who specialize in exoskeleton and high-end neuro-orthopedic fitting appeals and have successfully represented our clients hundreds of times? You should not just mandate a health insurance law specialist, but one who has represented exoskeleton patients.
The health insurance company has rejected your aid supply, respectively your health insurance company has rejected the application for exoskeleton? Our goal is to support you in the best possible way. It is not about fighting through your application with all legal means, but to have your case examined individually and to stand by you potentially in the impression of a wrong decision of the insurance company in the best possible way, so that you receive what you are entitled to. We know from experience that more than 50 % of claims are denied, but when appealed, 20 % are approved immediately. This means that a simple aid appeal can already help you succeed. However, it may also be necessary to file additional legal remedies.
We therefore recommend taking a specialist lawyer for medical law, specialist lawyer for social law or specialist lawyer for health insurance law from our network, as our cooperation partners have specialized in this type of case and have gained considerable experience through the large number of objections.
We will be happy to put you in touch with a contact person on site or digitally.
All of our partner law firms are required to offer you a free initial consultation and will also give you an assessment of the likelihood of success at this appointment. After that, you can decide whether you want to award the mandate.
Responsibility for organizing care lies with the competent body, which is either the rehabilitation provider or, if several payers are involved, the coordinating body. This body is also responsible for ensuring that the rights of the applicant are respected.
When applying for social security benefits in Germany, it is important to know that there are different cost units. Each carrier has specific provisions for the provision of benefits, which are regulated in the individual Social Security Codes or in the Severely Disabled Persons Compensation Levy Ordinance. If several cost units are involved in providing a service, then the Integration Office (SGB IX) is responsible for coordinating care. The aim is to provide the applicant with care as quickly and efficiently as possible. This is to ensure that the claimant receives all the benefits to which he or she is entitled and that these benefits are not unnecessarily paid twice. Responsibility for organizing care rests with the responsible agency, which is either the rehabilitation provider or, if multiple payers are involved, the coordinating agency. This body is also responsible for ensuring that the rights of the applicant are respected. When applying for social security benefits in Germany, it is important to know that there are different cost bearers. Each carrier has specific provisions for the provision of benefits, which are regulated in the individual Social Security Codes or in the Severely Disabled Persons Compensation Tax Ordinance. If several cost bearers are involved in the provision of a service, the Integration Office (the German coordination office for social benefits) is responsible for coordinating care. The goal is to provide care to the claimant as quickly and efficiently as possible. This is to ensure that the claimant receives all the benefits to which he or she is entitled and that these benefits are not unnecessarily paid twice. Responsibility for organizing care rests with the responsible agency,which is either the rehabilitation provider or, if multiple payers are involved, the coordinating agency. This agency is also responsible for ensuring that the claimant's rights are respected.
An application for an aid or a technical work aid is always made in writing. The applications are available from the service providers (rehabilitation provider or integration office).It is important to submit the application before the procurement or the start of a barrier-free construction measure and to set the Approval to be awaited. Different documents are required depending on the payer.
These include:
The cost estimate can be obtained from a service provider (medical supply store) or a company that manufactures or sells occupational aids or technical work aids.
The deadlines for the decision are also regulated in SGB IX (§ 14 ff.):
The responsible rehabilitation provider must decide on the service within three weeks of receipt of the application. This period is extended if it is a question of turbo clarification, if expert opinions have to be obtained or if other rehabilitation providers are involved. As a rule, each rehabilitation provider must decide on the service within three weeks of receipt of the application. This period is extended if it is a turbo clarification, if expert opinions have to be obtained or if other rehabilitation providers are involved. If other rehabilitation providers are jointly responsible, the responsible rehabilitation provider must to involve them and to carry out a binding participation plan procedure (§§ 19 - 23 SGB IX-neu). In complex cases, the responsible rehabilitation provider must hold a participation plan conference (with the applicant, the rehabilitation providers and, if applicable, the integration office if the latter is also a provider). The conference decides on the overall provision of services and the respective responsibilities of the rehabilitation providers. The "responsible" rehabilitation provider is the one who must make the decision whether or not to provide the service. If it decides not to provide the service, it must inform all other rehabilitation providers who are also responsible for providing the service. If one of these other rehabilitation providers decides to provide the service, it becomes the "providing rehabilitation provider." It is the one responsible for providing the service and must inform all other rehabilitation providers who are also responsible for providing the service. Each rehabilitation provider must make a decision on the service within three weeks of receiving the request. This period is extended if turbo-release is involved, if expert opinions must be obtained, or if other rehabilitation providers are involved.
If you are not satisfied with your service provider's decision because they refuse to pay for an aid or technical work aid, you have the right to appeal. However, you should be aware that a court case can take a very long time. In most cases in social law, an appeal procedure is required before court proceedings can be initiated.
In principle, the service providers must notify their refusal in writing.
The notice of rejection must contain instructions on how to appeal, indicating that the objection must be lodged within one month (§ 36 SGB X).
Appeal instructions may be invalid if they lack a reference to the possibility of transmission by De-Mail (cf. Judgment).
Within the applicable deadlines, insured persons must file the objection in writing with the relevant service provider or orally in writing at an office of the service provider:
Deadline one month: The time limit for appeal is one month if the appeal notice is in the rejection notice.
Deadline one yearThe time limit is extended if the information on the right of appeal is missing in the notice of rejection.
Start of deadlineThe time limit begins when the insured person receives the rejection notice.
Time limit for filing the grounds of opposition: You can give reasons for the opposition immediately or submit it later with a note - for example, with the wording "The reasons for this opposition are given separately."
Insured persons can formulate a letter of objection freely or alternatively appoint a lawyer. If the objection is successful, the service provider will reimburse the lawyer's fees. The reason for the objection must be explained urgently.
The reason should be formulated and substantiated with experts, e.g. the doctor or a lawyer. A medical report can be helpful as proof. The service provider may decide on the basis of the file, but must take into account all significant circumstances for the individual case and explain the reasons for the decision.
If the service provider bases its rejection on an expert opinion, for example from the Medical Service (MD) or an external expert opinion, insured persons should request this and, if necessary, carefully check it with the treating specialist.
If the medical report was only prepared on the basis of the files, insured persons should request a personal assessment. Insured persons have a right to inspect files according to § 25 SGB X.
Insured Persons are not required to respond to telephone or written inquiries from benefit providers as to whether Insured Persons maintain their appeal after the statement of reasons.
If the service provider does not decide on the objection filed within the period of three months insured persons can file an action for failure to act (§ 88 SGG) before the social court even without legal counsel. Insured persons must send the notice of rejection and the objection to the social court with the action. In many cases, the legal costs of the action for failure to act are borne by the service provider.
You can even procure the aid yourself! Insured persons can procure a benefit themselves in accordance with § 18 SGB IX if, after the expiry of two months no written justified notification is made by the service provider. The service is then deemed to have been approved.
If the benefit provider rejects the objection again, insured persons can appeal before the Social Court sue. The lawsuit must be filed within one month be filed. If the notice of appeal is missing in the notice of opposition, the time limit for filing an appeal is extended to one year. The time limit begins when the notice of appeal is received by the insured person, for example when it lands in the mailbox. Insured persons can file the complaint in writing with the competent social court or give the complaint orally on record. However, we strongly recommend mandating a specialist lawyer!
In court proceedings before the social court, although no court fees However, you reduce the risk of losing the lawsuit due to formal errors. The State Treasury will also pay for an expert opinion requested by the court. If this is unfavorable to the insured, they can book another expert of their own at their own expense. Plaintiffs can inspect the files in court and represent themselves in court without legal counsel. However, due to the financial risks and complex legal matter, legal advice and legal counsel in court are recommended.
If one has not been able to meet the objection or appeal deadline, they can reapply for the benefit. However, this causes further time delays at the expense of the insured person.
In urgent or emergency cases, the insured person can accelerate the proceedings by means of interim legal protection. This interim measures can be applied for at the social court (§ 86b SGG). Insured persons do not need legal assistance for this, but it is also recommended here.
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