Medical benefis

The basic assumption concerning medical benefits is that they comply with legal provisions relative to effectiveness, appropriateness and efficiency. Therefore there is no special list specifying which forms of treatment, benefits, etc. are subject to compulsory insurance coverage, with the exception of maternity, preventive, and dental treatment services.

Whenever coverage for a specific service is contested, an expert commission (Eidg. Kommission für allgemeine Leistungen, ELK) examines the case and voices a recommendation for or against coverage. The Federal Department of Home Affairs takes the final decisions, and publishes them in a special list (Anhang 1 der Krankenpflege-Leistungsverordnung, KLV). Certain benefits are subject to compulsory coverage for a limited period and under specific conditions, pending the results of relevant studies (complementary medical treatment, for example) allowing for a definitive decision.

Supplementary benefits

Chiropractors or other persons providing services prescribed by physicians and who fulfil the requirements pursuant to the Health Insurance Ordinance (KVV Art. 38 bis 52) (physiotherapists, occupational therapists, outpatient services, nutrition counselling, diabetes counselling, speech therapists, pharmacists), are reimbursed to the extent specified in the Health Care Benefits Ordinance (Krankenpflege-Leistungsverordnung KLV).

Prescripted medicine, products, analyses

Preventive measures

Screening or preventive measures prescribed or carried out by physicians are listed in full in Article 12 of the Health Care Benefits Ordinance Krankenpflege-Leistungsverordnung (KLV).

Maternity

Besides delivery, special screening tests during pregnancy and after parturition are covered, as well as the costs of antenatal classes, breast-feeding counselling, and midwifery. All these are listed in full in Articles 13 to 16 of the Health Care Benefits Ordinance 13 bis 16 der KLV.

Dental treatment

The compulsory health insurance reimburses dental treatment only in cases of severe unavoidable diseases of the mastication system, dental treatment required due to a critical general medical condition, or treatment needed to back up and ensure medical treatment for a critical general medical condition. In the case of accidents, reimbursement sets in only if no other insurance covers the costs of treatment. The costs of normal fillings for caries or corrective treatment (braces for children) are not covered. Articles 17 bis 19a der Krankenpflege-Leistungsverordnung (KLV) list all indications that are grounds for coverage in full. 

Medical spas - ambulance & rescue

For a prescribed cure at an authorised medical spa (see decision [in German] from 17th January 2001 and from 21st December 2001 1), CHF 10 per day are reimbursed for a maximum period of 21 days. Additional costs of medical treatment or physiotherapy are reimbursed separately.

If for medical reasons a special means of transport (an ambulance, for example) is required, or the patient's health status makes transport by regular public or private means impossible, half the costs are reimbursed up to a maximum amount of CHF 500 per year. These provisions are valid abroad.

The basic health care insurance also pays half the costs of the rescue of persons in a critical condition (e.g. after a heart attack or accident in the mountains), up to a maximum of CHF 5000 per year (in Switzerland only).

(1) Those medical spas are reserved, which required a permission but there are still no valid decisions.

Franchise and
contribution to the medical costs

Medical evacuation

Repatriation in the home country or Switzerland

Worldwide coverage

Outside of Switzerland, covered are only the emergency cases with a maximum of the double of the Swiss medical tariffs.