Saturday, April 20, 2024

What Erectile Dysfunction Treatment Costs Does Health Insurance Cover?

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Erectile dysfunction (ED) is recognized as a medical condition by both healthcare professionals and legal authorities, with landmark rulings by the Federal Social Court (BSG) in 1999. However, the coverage of treatment costs depends on public or private health insurance. Since 2004, drugs treating ED, including PDE5 inhibitors (e.g., Cialis, Viagra), have been excluded from statutory health insurance coverage. The BSG upheld this decision, citing the subjective nature of ED’s transition between pathological and non-pathological states. Consequently, legal challenges in Germany are generally unsuccessful. In contrast, Austria has established coverage for ED drugs.

Ironically, only drugs are excluded from coverage by statutory health insurance, while all other medical services for diagnosing and treating erectile dysfunction remain part of the benefits catalog. Consultation and treatment by a specialist, as well as diagnostics and all related procedures (such as blood tests, SKIT, and ultrasound), are covered by health insurance.

However, you need to be cautious here, as some specialists unfortunately attempt to bill follow-up consultations as private services after the initial appointment. Terms like “initiated,” “extended,” or “continued” treatment are invented for this purpose. All counseling services and diagnostic procedures are covered by insurance and should not be paid for privately. If a doctor attempts something like this, it’s best to find a new one.

Coverage of Erectile Dysfunction Treatments for Insurance Holders

The benefits catalog of statutory health insurance still includes aids such as vacuum erection devices and erection rings. So, you don’t have to pay for these if a doctor diagnoses you with erectile dysfunction. Psychotherapeutic treatment is also still covered by statutory insurance. Additionally, testosterone replacement therapy (all forms) and surgical procedures, such as the insertion of penile implants, are covered.

Private health insurers were initially unaffected by healthcare reforms in this area. Your situation as a privately insured individual depends on the policy you have with your private health insurer. Which services are covered by the insurance depends on the inclusions or exclusions listed in your policy. You’ll need to check your policy for details.

Erectile Dysfunction

Private Health Insurance and Erectile Dysfunction Treatment

Coverage for the treatment of erectile dysfunction may be directly excluded from the policy or listed in the appended schedule of benefits. The wording or specific areas of the exclusion matter. For example, a clause might exclude potency-enhancing agents but cover the treatment of diagnosed erectile dysfunction, including medication.

However, private health insurers unfortunately sometimes refuse coverage. Whether to file a lawsuit in such a case needs careful consideration. Having to pay for the medications yourself can quickly become a significant financial burden. Nevertheless, you should seek legal advice if your private health insurer denies coverage.

In cases of litigation, it’s worth noting that courts have not consistently ruled on these matters in the past. In addition to the specific policy, the legal arguments can be very individual. It’s also possible that certain exclusion clauses are legally invalid, giving you even more reason to seek legal assistance.


Resource: Impotenz Selbsthilfe, December 2023

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