Reader question: Can my Swiss health insurance refuse to pay my medical bills?

Switzerland’s compulsory basic insurance — KVG in German and LaMal in French and Italian — is quite comprehensive and includes coverage for illness, medications, tests, maternity, physical therapy, preventive care, and many other treatments.

It also covers accidents for those who do not have accident insurance through their workplace.

Basically, whatever the doctor orders is covered by KVG / LaMal - at least partially.

So you can rest easy that any medically necessary, doctor-prescribed treatment will be paid for by your insurer. You can ask your insurance company to send you a detailed list of everything your basic plan covers.

Keep in mind though that while the basic insurance allows policyholders to choose their own GPs and consult specialists of their choice without a referral, these rights are limited if you buy a cheaper but more restrictive plan like the Health Maintainance Organisation (HMO), Telmed, or Family doctor model.

All of them require you to get prior approval of doctors for non-emergency care. If you don’t, these insurance plans will not pay if you break the rules laid out in your contract.

While KVG / LaMal is pretty comprehensive in terms of coverage, there are nevertheless some health-related costs it will not pay.

Experimental treatments

Any experimental treatments or drugs — that is, those not approved by the Swissmedic regulatory agency or the Federal Office of Public Health (FOPH), will not be covered.

This exclusion is not specifically Swiss; insurance schemes in most countries won’t cover unauthorised medical treatment either.

Dental care

In most cases, services such as teeth cleaning, dental fillings, root canals, tooth extractions, and orthodontic braces, are not included under basic insurance.

The only exceptions, according to FOPH, are dental interventions “necessitated by a serious disorder of the masticatory system, or if such treatment is required to support and ensure the success of medical treatment for a severe general disorder (e.g. leukaemia, heart-valve replacement)”.

The insurance will also pay for dental treatment if you break your teeth or sustain any other injury to your mouth as a result of an accident which, in itself, is covered either by your workplace accident insurance or KVG / LaMal (as stated above).

This won't be paid for, except in certain cases. Photo: Reto Gerber from Pixabay

Eyeglasses and contact lenses

Compulsory health insurance will contribute up to 180 francs per year towards glasses and contact lenses prescribed by an ophthalmologist for children up to the age of 18.

No such benefit exist for adults. However, “in the case of serious visual impairment or certain illnesses (e.g. disease-related refraction abnormalities, postoperative alterations or corneal disease), compulsory health insurance will, regardless of age, make higher contributions towards medically prescribed spectacle and contact lenses”, FOPH says.

Ambulance

Emergency vehicles that transport you to a hospital can be quite expensive — depending on the canton, the costs can range from 900 to 2,000 francs per trip. 

Basic health insurance will contribute a certain amount  to the cost of emergency transportation, but only if it is a vital necessity — a serious accident, an illness, or a life-threatening situation. But if the patient could have travelled by private car or public transport, basic health insurance policies will pay nothing.

READ MORE: Reader question: Am I liable for ambulance costs in Switzerland?

Private hospital room

While the cost of your hospitalisation will be fully covered, the basic insurance does not pay for a private room.

You will be accommodated in a room with other patients.

Depending on a medical facility — whether it’s a small hospital or a large, university medical centre, you could end up with just one other person or possibly four or five, the latter being common in teaching hospitals.

If you insist on a private accommodation, you will have to pay for it out of your own pocket.

Vaccines

Insurance will pay for some immunisations, like the Covid vaccine or the recommended childhood shots.

Not covered, however, are travel-related vaccinations or preventive measures, such as against yellow fever or malaria.

As far as flu shots, they will be covered for people over the age of 65 and for youger ones if they suffer from serious medical conditions in which infection with the flu virus could have serious consequences.

Some vaccines are covered, others aren't. Photo: Angelo Esslinger from Pixabay

Hospital care in another canton

It all depends on what kind of medical help you are seeking.

For instance, if, for whatever reason you want to consult a doctor or get an elective surgery in another canton, your basic health insurance will not totally cover the costs.

The KVG / LaMal will only pay for treatment (both outpatient and in-hospital) in the canton where the patient lives.

However, this rule applies only to non-urgent situations; emergency cases are treated differently.

If you injure yourself skiing or require urgent surgery while visiting another canton and can’t be easily transferred to a hospital close to your home, then your insurance will cover all the the costs of medical treatment.

FOPH defines “emergency” as a situation when “your state of health does not permit you to be taken to a hospital in the canton where you live. You will be transferred to a hospital in the canton where you live as soon as this is possible and sensible".

FOPH also allows out-of-canton treatment for "particular medical reasons" — that is, if the required care can’t be provided at a public healthcare facility in your canton of residence.

Why are you limited to your canton of residence for non-emergency care?

The reason is that health insurance premiums vary from one canton to another, based on the health infrastructure and levels of government funding they receive.

Demographics and statistics also play a role: health premiums in cantons with younger and healthier population will be lower than in those with higher incidence of disease, and older, chronically ill people.

So your insurance carrier won’t like it if you choose to have elective surgery or another non-urgent treatment in a canton with higher rates.
 
READ MORE: Will my Swiss health insurance cover treatment in another canton?

Treatment abroad

Outside Switzerland, only emergency care is covered  — double the amount that the same treatment would cost in Switzerland.

Usually, basic health insurance will not cover transportation costs back to Switzerland, except in case of emergency, when it will cover 50 percent of the total cost of transportation to the nearest hospital abroad — but not more than 500 francs per year. 

If you only have a basic insurance policy and travel abroad often, especially to the United States, you should take out a travel insurance that will cover you for illness and accidents in foreign countries above and beyond what your Swiss carrier will pay.

This is what KVG / LaMal will (and won't) do for you.

If you want to have more leeway in what benefits you get, you have the option of taking out a a supplemental insurance

Complementary policies will pay for many health and wellness treatments that KVG / LaMal won’t touch. You can see all the benefits these plans offer here:

Acupuncture to rolfing: What your Swiss health insurance gets you (if you pay more)