Fictitious Approval (Genehmigungsfiktion)
Under Germany's statutory health insurance, a benefit application is deemed approved if the fund fails to decide within the statutory deadline.
Concept
Under Section 13(3a) of Book V of the German Social Code (SGB V), the fictitious approval rule applies in statutory health insurance: if a health insurance fund fails to decide on an application for a benefit within a statutory deadline (generally three weeks, or five weeks if an expert opinion is required), the requested benefit is deemed approved.
Requirements and Effect
Fictitious approval takes effect if the health insurance fund neither communicates a decision to the insured within the deadline nor provides sufficient reasons for a delay; once the fiction takes effect, the requested benefit is deemed approved, allowing the insured to obtain the benefit itself and demand reimbursement from the health insurance fund, without the substantive merits of the original application still mattering.
Relevance for Insured Persons
Fictitious approval significantly strengthens the position of insured persons vis-à-vis health insurance funds by creating an effective incentive for prompt processing of benefit applications; the precise scope of the rule, particularly regarding which types of benefits are covered by the fiction, has been and remains the subject of extensive social court case law.