If your health insurer in Switzerland does not pay a medical bill in full, this does not necessarily mean that your claim has been denied. The amount may have been applied to your deductible or co-payment, the insurer may be missing supporting documents, or the original bill from the doctor or hospital may contain an error.

This is important for anyone receiving medical treatment and health insurance statements in Switzerland. This guide explains how to check the documents, whom to contact in different situations, and how to challenge a decision concerning mandatory basic health insurance.

First, check which document you have received

After receiving medical treatment in Switzerland, you may be sent several different types of documents:

• a bill from a doctor, hospital, laboratory or pharmacy;
• a copy of a bill that the healthcare provider sent directly to your insurer;
• a benefits statement showing what the insurer covered and what you must pay;
• a notice stating that certain costs are not covered;
• a formal decision from the insurer, known as a Verfügung in German.

These documents are not the same.

A medical bill shows what the healthcare provider charged. The insurer’s benefits statement shows how those costs were allocated between the insurer and the insured person. A Verfügung, meanwhile, is a formal decision that can be challenged through the applicable legal procedure.

Why does the bill sometimes come to you and sometimes go directly to the insurer?

Switzerland has two main medical billing systems.

Under the Tiers garant system, the patient receives the bill first. The patient sends it to the insurer, which reimburses the covered amount after deducting the applicable deductible and co-payment. This system is commonly used for outpatient treatment.

Under the Tiers payant system, the doctor, hospital or pharmacy sends the bill directly to the insurer. The insurer pays the healthcare provider and then charges the insured person for their share of the costs. This system always applies to inpatient hospital treatment.

Receiving a bill yourself therefore does not necessarily mean that your insurer has refused to pay it. You may simply need to submit the bill to the insurance company.

How much patients ultimately pay depends on factors such as their deductible, co-payment and the extent of their insurance coverage. Photo: THICHA SATAPITANON/Shutterstock.com

Situation 1: The bill includes a service you did not receive

Check the following details:

• Is your name correct?
• Is the date of treatment correct?
• Did you receive all the services listed?
• Does the recorded duration of the consultation roughly correspond to the actual appointment?
• Are any items duplicated or unclear?
• Have you been charged for a cancelled appointment or for another person’s treatment?

Patients are not expected to understand every medical or tariff code. However, if you notice an obvious discrepancy, you should ask for an explanation.

In this situation, your first point of contact will usually not be the insurance company. Contact the healthcare provider that issued the bill: the doctor’s practice, hospital, laboratory or billing service.

The insurer was not present during the consultation and may have no way of knowing which services were actually provided.

Identify the exact item you are questioning and request either an explanation or a corrected bill. If the payment deadline is approaching, do not simply ignore the invoice. Ask in writing for the collection process to be suspended or for the payment deadline to be extended while the bill is being reviewed.

Since 2022, healthcare providers have been required to send insured patients a copy of their bill without being asked, even when the original is sent directly to the insurance company. One purpose of this rule is to allow patients to check their medical bills and report possible errors.

If you have not received a copy, you can request one from the healthcare provider or your insurer.

Situation 2: The treatment was covered, but you still have to pay

This is one of the most common sources of confusion.

Under mandatory basic health insurance, adults must first cover their healthcare costs up to the amount of their chosen annual deductible, known as the Franchise. The standard deductible is CHF 300, although adults can voluntarily choose a higher amount.

Once the deductible has been reached, the insured person usually continues to pay 10% of the remaining costs. This is the co-payment, known as the Selbstbehalt. For adults, the total annual co-payment is generally capped at CHF 700.

An additional hospital contribution of CHF 15 per day may also apply during an inpatient hospital stay. Certain groups are exempt, including children, young adults under the age of 25 who are in education, and women receiving maternity-related care.

For example, imagine that you have chosen a deductible of CHF 2,500 and have not incurred any other medical costs during the current year. Your insurer may confirm that the treatment is covered under basic insurance but reimburse nothing because the entire amount is still being applied to your deductible.

This is not a refusal of insurance coverage. The insurer has accepted the bill, but under the applicable cost-sharing rules, you are still responsible for paying it.

The deductible is calculated per calendar year. The date of treatment matters, not the date on which you receive the bill.

Situation 3: The insurer has actually refused coverage

First, ask the insurer to explain the specific reason for the refusal. Do not limit your question to: “Why are you not paying?”

Find out:

• whether the service is covered by mandatory basic health insurance;
• whether prior approval of the costs—a Kostengutsprache—was required;
• whether the insurer has received all the relevant medical documents;
• whether an additional medical opinion is needed;
• whether you followed the rules of your insurance model;
• whether the insurer considers the treatment medically necessary;
• whether another insurance provider should be responsible for the costs.

If you have a family doctor, HMO or Telmed insurance model, check its specific rules as well. Problems can arise when an insured person consults a specialist without the required referral or fails to contact the designated telemedicine service before seeking treatment.

The consequences depend on the particular insurance model and the terms of the policy.

During a phone call, record the date, the employee’s name and the main points of the explanation. Afterwards, it is advisable to confirm the important details briefly by email or letter.

Check whether the case concerns basic or supplementary insurance

This distinction is essential because the procedures for challenging a decision are different.

Mandatory basic health insurance, known as Grundversicherung, is governed by the Swiss Health Insurance Act, referred to as KVG in German and LAMal in French and Italian. All authorised basic health insurers must provide the range of benefits defined by law.

Supplementary health insurance, or Zusatzversicherung, is based on a private insurance contract. Coverage depends on the specific policy and its terms. It may include benefits such as complementary medicine, private hospital accommodation, treatment abroad, dental care or other additional services.

The same insurance company may provide both your basic and supplementary health insurance. Legally, however, these are two different insurance relationships.

The Verfügung and Einsprache procedure that applies to mandatory basic insurance cannot automatically be used for a supplementary insurance dispute.

How to challenge a decision under mandatory basic health insurance

If the insurer’s explanation does not resolve the matter, you can ask it to issue a formal written decision, known as a Verfügung.

The document should include:

• the insurer’s decision;
• the reasons for the decision;
• the legal basis;
• instructions explaining how and by when the decision can be challenged.

Once you receive the Verfügung, you normally have 30 days to submit a formal objection, known as an Einsprache, to the same insurance institution.

Your objection should clearly state:

• which decision you are challenging;
• what part of it you disagree with;
• what outcome you are requesting;
• which documents support your position.

The insurer will reconsider the case and issue an objection decision, known as an Einspracheentscheid.

If you disagree with that decision, you may appeal to the competent cantonal insurance court. The decision should specify where the appeal must be submitted and which deadline applies.

You do not need to demand a Verfügung every time a question or minor discrepancy arises. In many cases, an explanation or a missing document is enough to resolve the issue. But if the insurer maintains its position, obtaining a formal decision opens the way to a legal challenge.

What if the dispute concerns supplementary health insurance?

Ask the insurer to identify in writing the specific provision of the policy or insurance terms on which the refusal is based.

Include the following documents with your enquiry:

• your insurance policy;
• the general and supplementary insurance terms;
• the insurer’s refusal letter;
• medical bills;
• medical reports;
• previous correspondence;
• any written prior approval of the costs.

If you cannot resolve the matter directly with the insurer, you can contact the Swiss Health Insurance Ombudsman. In complex cases or disputes involving a substantial amount of money, you may need independent legal advice.

Could another insurer be responsible for the bill?

If the treatment is related to an accident, the costs may not be handled through your regular health insurance.

Employees who work for the same employer for at least eight hours per week are generally insured through their employer for both occupational and non-occupational accidents.

People who are not employed, or who work fewer than eight hours per week for the same employer, will usually need accident cover to be included in their mandatory basic health insurance.

After an injury, it is therefore important to report the circumstances correctly to your employer, the accident insurer and the healthcare provider.

A refusal from your health insurer does not always mean that the treatment is not covered at all. It may mean that another insurer is responsible for assessing and paying the bill.

A medical bill does not necessarily mean your insurer has refused to cover the treatment — some of the costs may simply fall under your deductible or co-payment. / Photo: Rawpixel.com/Shutterstock.com; adapted by UAinfo

When can the Ombudsman help?

The Swiss Health Insurance Ombudsman provides free advice and mediation in cases involving misunderstandings or disputes between insured people and health insurers.

You may wish to contact the Ombudsman if:

• you do not understand your insurer’s benefits statement;
• you disagree with a refusal to cover treatment;
• the insurer is not responding;
• your own correspondence with the insurer has not resolved the issue;
• you are unsure what to do next.

The Ombudsman can review the documents, explain the legal situation and contact the insurer if there appears to have been an error. However, the Ombudsman is not a court and cannot issue a legally binding decision.

Most importantly, contacting the Ombudsman should not be assumed to extend or suspend an appeal deadline automatically. If a Verfügung, Einspracheentscheid or another document already specifies a deadline, you must take separate steps to ensure that you meet it.

A step-by-step checklist

If you are surprised by a medical bill or health insurance decision:

1. Identify who issued the document: the doctor, hospital or insurer.
2. Check the dates, services and amounts.
3. Find out whether the amount was applied to your deductible or co-payment.
4. Determine which insurance is involved: basic health insurance, supplementary insurance or accident insurance.
5. Ask what information or supporting documents may be missing.
6. Confirm the important points in writing after a phone conversation.
7. Do not ignore payment or appeal deadlines.
8. If a refusal under basic health insurance remains in place, request a Verfügung.
9. Contact the Ombudsman or seek legal advice if necessary.

The key points to remember

An unexpected amount does not always indicate an error. Similarly, receiving no reimbursement does not necessarily mean that your insurer has refused to cover the treatment.

Start by separating three different questions:

• Did the healthcare provider issue the bill correctly?
• Did the insurer calculate your share of the costs correctly?
• Was the insurer legally entitled to refuse coverage?

Once you know where the problem occurred, the next step becomes much clearer. You may need to ask the healthcare provider to correct the bill, submit a missing document, request a written explanation or begin the formal appeal process.

Useful contacts and official information

• Federal Office of Public Health: premiums and cost sharing
• Federal Office of Public Health: medical benefits, tariffs and billing systems
• Swiss Health Insurance Ombudsman
• Ombudsman of Private Insurance and Suva
• Swiss Health Insurance Act—KVG
• Federal Act on the General Part of Social Insurance Law—ATSG
• Swiss Insurance Contract Act—VVG

This article is intended for general information only. The appropriate course of action in an individual case will depend on the type of insurance involved, the terms of the policy and the documents you have received.