Does German statutory health insurance cover a private house call?

Why GKV does not pay — and what alternatives exist

German statutory health insurance (GKV) works on the benefit-in-kind principle: you present your insurance card, the doctor settles directly with the regional KV under the EBM schedule, and you pay nothing (apart from prescription co-payments). Private doctors stand outside this system — they bill under GOÄ, the German fee schedule for physicians, directly with the patient. If you, as a statutorily insured patient, book a private house call, you act as a self-payer. The insurance does not reimburse this bill — not partially, not in emergencies.

This is a deliberate legal separation, not a bug. GKV covers out-of-hours house calls through the contract-physician on-call service, reachable at 116117 outside practice hours and via your regular GP during office hours. The system works: at weekends or at night a contracted physician comes to you and you pay nothing. The problem in Berlin is wait times. 116117 house calls in Berlin often take 4 to 8 hours — sometimes longer during flu season. Anyone who cannot or will not wait deliberately chooses the faster private route and pays for it.

There are three constellations where the GKV may still cover part of the cost. First: if a genuine emergency occurred and no contract physician was reachable, you can apply for cost reimbursement under § 13 (3) SGB V — the success rate is low but not zero, and you need a doctor's certificate documenting the situation. Second: if you hold supplementary private insurance with a 'private doctor' tariff, the house call is reimbursed there — typically up to factor 2.3 or 3.5 depending on the tariff. Third: self-employed and higher-earning patients should evaluate whether a switch to full PKV makes long-term sense. On the phone we always tell you honestly whether GKV reimbursement is realistic.

Example: working mother in Neukölln

A GKV-insured mother in Neukölln has a feverish child with persistent cough and poor general condition on a Saturday morning. She calls 116117 and is offered a callback slot in six hours. Unwilling to spend the weekend waiting with a sick child, she books a private house call — the doctor arrives within 75 minutes, examines the child, rules out pneumonia, prescribes antipyretic measures and issues a certificate. She carries the 280-euro bill as a self-payer. With supplementary insurance she would have been reimbursed; without it she absorbs the cost as a conscious choice for fast help on a difficult day.

When a GKV patient sensibly books a private house call

• When you want to avoid the long 116117 wait times (often 4 – 8 hours in Berlin) and accept the self-payment knowingly.
• If you hold supplementary private insurance with an outpatient private-doctor tariff — the house call is reimbursed there.
• Foreign tourists with travel insurance who fall ill in Berlin — travel insurance usually covers the house call.
• Urgent matters outside the emergency definition: gastroenteritis, respiratory infections, migraine, back pain, urinary tract infection.
• Acute symptoms in a hotel or unfamiliar environment where your regular GP is unreachable.
• Very elderly or mobility-impaired patients whose GP no longer does house calls and who cannot wait four hours.
• Language barriers: English- or multilingual contract physicians cannot be specifically selected via 116117.