Case management

What is case management?

Case management is a method insurers use to support individual difficult cases personally. A specialist, usually trained in nursing, social work or insurance, takes over the coordination around an insured person. They are the contact person for you, for the treating doctors, for your employer and for other insurers.

Case management is used where many parties have to work together: after a serious accident, with cancer, with a long mental illness, with several chronic illnesses or when a long period of incapacity for work is likely. The aim is for treatment to run without gaps, for benefits to be approved in good time and for the return to work to succeed.

In the Swiss healthcare system, several players offer case management:

• Daily sickness allowance insurers: they pay a daily allowance while you are unable to work and have a direct interest in a quick return to work. Daily sickness allowance insurance is usually a collective contract taken out by the employer under the Insurance Contract Act (ICA).
• Accident insurers under the Accident Insurance Act (UVG): after serious accidents, they support recovery, rehabilitation and the return to work.
• Disability insurance (IV): the IV offices carry out the early detection and early intervention laid down by law in order to prevent disability.
• Health insurers: some insurers offer programmes for complex or chronic illnesses in basic or supplementary insurance, often under other names such as health coaching or treatment coaching.

Case management must be distinguished from managed care. Managed care refers to insurance models with a restricted choice of doctors that apply to everyone insured under a given product. Case management, by contrast, starts with the individual case and is not a choice of model. It must also be distinguished from the medical adviser: the medical adviser checks from a medical point of view whether an insurer has to pay and advises the insurer. The case manager coordinates but does not make medical decisions or decide alone whether benefits are owed.

How it works

Case management typically runs in five steps. The terms differ from one insurer to another, but the pattern is similar:

1. Trigger: the insurer identifies a case that needs coordination, for example because incapacity for work lasts several weeks, expensive treatment is due or several insurers are involved. You yourself, your employer or your doctor can also suggest case management.
2. First meeting and consent: the case manager explains the purpose and the procedure. Exchanging information with doctors, your employer and other insurers requires your authorisation. You can limit it to individual bodies or topics.
3. Analysis of the situation: together you record what is happening medically, what limitations exist, what the work situation looks like and which insurers are responsible.
4. Plan and coordination: a plan of measures with goals and dates is drawn up, for example a gradual return to work at 50%, an adjustment to the workplace or organising rehabilitation. The case manager obtains cost approvals and coordinates with the other bodies.
5. Closure: case management ends when the goals have been reached, when no further progress is possible or when another body, such as the IV, takes over.

For disability insurance, the procedure is laid down by law. Reports for early detection can be made by the insured person themselves, family members in the same household, the employer, the treating doctors, the daily sickness allowance insurer, the accident insurer and other bodies. Anyone who reports you (except you yourself or your legal representative) must inform you beforehand. The IV office assesses your situation and decides no later than 30 days after receiving the report whether early intervention measures are appropriate. Such measures include, for example, workplace adjustments, training courses, career guidance, or advice and support.

Legal basis

For health insurers, there is no statutory definition of case management. Neither the Federal Health Insurance Act (KVG) nor the Health Insurance Ordinance (KVV) uses the term. Insurers offer it as part of their benefit assessment and customer service. In supplementary and daily sickness allowance insurance under the ICA, the framework results from the policy and the general terms and conditions.

Several provisions nevertheless form the framework:

• Art. 28 ATSG requires insured persons and employers to cooperate free of charge in implementing the social insurance acts. Anyone who claims benefits must provide the necessary information and authorise the bodies concerned to provide information in the individual case (paras. 2 and 3).
• Art. 43 ATSG requires the insurer to carry out the necessary investigations of its own accord. If you fail to meet your duty to cooperate without an acceptable excuse, the insurer can decide on the basis of the file after a written warning and time to reconsider (para. 3).
• Art. 57 KVG governs the position of medical advisers. They are independent in their assessment and pass on to the insurer’s departments only the information needed to decide on the obligation to pay benefits, reimbursement, risk equalisation or a written decision (paras. 5 and 7).
• Art. 3a–3c IVG govern advice, early detection, reporting and the IV procedure. Under Art. 3c para. 5 IVG, the IV office informs the daily sickness allowance insurer, the health insurer and the accident insurer, among others, whether early intervention is appropriate, but does not forward the medical documents.
• Art. 7d IVG lists the early intervention measures and states that there is no legal entitlement to them. Art. 1quater IVV sets the 30-day deadline for the decision, and Art. 1octies IVV caps the costs at CHF 20,000 per person.

The processing of health data is also governed by the provisions of the individual social insurance acts and the Federal Act on Data Protection (FADP). Under Art. 5 let. c FADP, health data is sensitive personal data.

Example: returning to work after an operation

Sandra, 47, works full time as an administrator. After back surgery, she is fully unable to work from 1 March 2026. Her employer has collective daily sickness allowance insurance. After six weeks, a case manager from the daily sickness allowance insurer contacts her. The dates and amounts in the example are fictitious; the deadlines and caps come from the IVG and IVV.

What this means for you

If a case manager contacts you, it is not a vote of no confidence. But it is worth taking an active part in the decisions:

1. Ask about their mandate and role. Which insurer does the person work for? What is the goal? Who receives which information?
2. Limit the authorisation. You can restrict the authorisation to certain bodies, topics and a set period. Do not sign a blanket authorisation without reading it.
3. Keep control of medical decisions. You make treatment decisions with your doctors. Case management organises; it does not prescribe.
4. Document agreements. Write down what was agreed, such as workload, dates and responsible bodies.
5. Get support in a dispute. In a dispute with your health insurer, the Office of the health insurance ombudsperson can help; against decisions by social insurers, you can take legal action by lodging an objection and an appeal.

Whether and how an insurer offers case management or programmes for chronic illnesses can be seen in the health insurer profiles. If you are treated frequently and over a long period, you can also check whether a model with a fixed first point of contact suits you: you can compare the premiums in the premium calculator, and the transitions when switching insurer are explained under Switching insurer. If you have questions about your insurance situation, you can get in touch via Request advice.

Common mistakes

• Confusing case management with control. The case manager does not check whether you are “really ill”. That is the task of the medical adviser’s service, under clear legal rules.
• Signing blanket authorisations. An unlimited release from medical confidentiality is rarely necessary. Limit it to what the case requires.
• Being reluctant to report to the IV. Early detection is not an application for a pension. It opens access to early intervention such as workplace adjustments or coaching.
• Refusing to cooperate without knowing the consequences. If you want social insurance benefits and fail to cooperate without an acceptable excuse, you risk a decision based on the file after a warning.
• Insisting on a legal entitlement. There is no legal entitlement to early intervention; the IV decides on a case-by-case basis.

We explain how we work with sources and legal provisions under How we calculate.