When the PKV pays – and when not

Judgment sets strict limits

Weight loss injection: When the PKV pays – and when not

Weight loss injections are popular but expensive. Even those who have private insurance can only insist on costs being covered under certain circumstances.

Statutory health insurance companies generally do not pay for so-called weight loss injections. This was recently confirmed by the Lower Saxony-Bremen State Social Court. But what does private health insurance look like?

A current ruling by the Nuremberg-Fürth Regional Court (Az: 8 O 4860/25) shows: Private health insurers also only have to pay for drugs like Mounjaro under certain conditions.

The specific case involved a man with private health insurance who had been prescribed a medication containing the active ingredient tirzepatide by his family doctor due to his high body mass index (34.29). This resulted in costs of around 3,100 euros in the following months.

However, the insurance did not want to cover these costs. The drug is – if it is purely used for weight loss – a “lifestyle drug”. Treatment is therefore not medically necessary and therefore cannot be paid for by insurance. The regional court also agreed with this view.

The judges made it clear that a health insurer only has to bear the costs if this is “actually necessary”. The man was unable to present a concept of how he had tried to get over his excess weight in the past. The blanket reference he made to diets, nutritional advice and exercise is not enough.

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In the court’s opinion, the man had therefore skipped obvious, recognized and cheaper measures to reduce weight. “The weight loss injection may be easier and more convenient to integrate into your everyday life. However, this cannot be done at the expense of the insured company,” the court ruled.

Since the man could not prove that he suffered from other comorbidities, the court rejected his claim for reimbursement of costs.

The ruling is also relevant because more than one in two adults in Germany now weigh too much weight. According to the Federal Statistical Office, 53.4 percent of adults in Germany have a body mass index (BMI) of over 25. From this value onwards, the World Health Organization (WHO) classifies adults as overweight. Almost one in five (17.9) even has a BMI of over 30 and is therefore considered obese.