Key points at a glance
- Congenital disorders are illnesses that exist when the birth is complete (Art. 3 para. 2 ATSG).
- Invalidity insurance (IV) covers medical measures for congenital disorders until the age of 20 (Art. 13 IVG).
- Which congenital disorders are covered is set out in the list of the FDHA Ordinance on Congenital Disorders (GgV-EDI), in force since 01.01.2022.
- The entitlement ends at the end of the month in which the person turns 20 (Art. 3ter para. 2 IVV).
- Basic health insurance covers congenital disorders without IV cover like an illness (Art. 27 KVG).
What is a congenital disorder?
Under Art. 3 para. 2 of the Federal Act on the General Part of Social Insurance Law (ATSG), a congenital disorder is an illness that exists when the birth is complete. This includes congenital malformations, genetic diseases and conditions that arose before or during the birth. However, not every congenital peculiarity is a congenital disorder within the meaning of invalidity insurance. To qualify, it must be on a federal list and meet certain criteria.
The list is in the annex to the Ordinance of the Federal Department of Home Affairs (FDHA) on Congenital Disorders (GgV-EDI). It is structured and numbered by organ system, for example no. 182 for congenital club foot, no. 201 for cleft lip, jaw or palate, or no. 313 for congenital malformations of the heart and blood vessels, provided that therapy or regular specialist check-ups are needed. Many numbers contain such conditions.
The term matters for health insurance because it determines who pays: invalidity insurance until the 20th birthday, otherwise basic health insurance.
How it works
Invalidity insurance (IV) covers medical measures to treat a congenital disorder if, under Art. 13 para. 2 of the Federal Act on Disability Insurance (IVG), it meets five criteria: it has been diagnosed by a specialist, it impairs health, it reaches a certain degree of severity, it requires long-term or complex treatment, and it can be treated with medical measures. The last criterion does not apply to trisomy 21.
The process:
- Diagnosis: A specialist doctor identifies the congenital disorder.
- Registration: The parents register the child with the IV office of their canton of residence.
- Decision: The IV office checks whether the disorder is on the list and meets the criteria, and issues a written decision.
- Treatment: Invalidity insurance covers the costs of treatment, medicines and aids and appliances under Art. 14 IVG. The health insurer’s co-payment with deductible and retention fee does not apply to this treatment.
- End at 20: The entitlement ends at the end of the month in which the person turns 20. After that, basic health insurance pays.
While invalidity insurance is still examining the case, the health insurer must pay in advance if it is unclear who is responsible (Art. 70 ATSG). If invalidity insurance refuses because the disorder is not on the list or does not meet the criteria, basic health insurance covers the treatment as it would an illness.
Legal basis
The definition is in Art. 3 para. 2 ATSG. Art. 13 IVG governs the entitlement to medical measures until the age of 20, and Art. 14 IVG their scope. Under Art. 14ter para. 1 let. b IVG, the Federal Council determines the congenital disorders; Art. 3bis of the Invalidity Insurance Ordinance (IVV) delegates this to the FDHA, which keeps the list in the GgV-EDI. Art. 3ter IVV governs the start and end: at the earliest after the birth is complete, until the end of the month of the 20th birthday.
For health insurance, Art. 27 of the Federal Health Insurance Act (KVG) applies: for congenital disorders that are not covered by invalidity insurance, basic health insurance covers the costs of the same benefits as for illness. It covers dental treatment for certain congenital disorders under Art. 19a of the Health Care Benefits Ordinance (KLV). The order of the insurances for medical treatment is set out in Art. 64 para. 2 ATSG: invalidity insurance comes before health insurance.
Example: treatment until 20, then the health insurer
Mia is born on 15.03.2026 with a congenital malformation that is on the GgV-EDI list. Her parents register her with the IV office.
| Period | Who pays for the treatment | Co-payment |
|---|---|---|
| from birth until 31.03.2046 | Invalidity insurance | no deductible, no retention fee |
| from 01.04.2046 | Basic health insurance | Deductible and retention fee |
| other illnesses, at any time | Basic health insurance | for children no standard deductible, 10% retention fee |
What this means for you
- Register early: Register your child with the IV office as soon as the diagnosis is available. Without registration, the invoices go through the health insurer with co-payment.
- Take out basic health insurance: Every newborn must have basic health insurance within three months of the birth; cover then applies retroactively from birth (Art. 3 para. 1 and Art. 5 para. 1 KVG), and the insurer must accept the child without reservation. You can compare premiums in the premium calculator or in the children’s premium calculator.
- Clarify supplementary insurance early: Before the birth, ask about the conditions for registration before birth. You will find an overview of the insurers under health insurers.
- Plan the transition at 20: From the month after the 20th birthday, the deductible and retention fee apply. Review your choice of deductible at that point.
- Check dental treatment: For jaw misalignments, invalidity insurance decides on the basis of the measurements in the list; more on this under orthodontics.
Common mistakes
- Informing only the health insurer. Invalidity insurance only pays after registration and a written decision by the IV office.
- Assuming every congenital peculiarity is covered. Invalidity insurance only pays for disorders on the list that meet the criteria of Art. 13 IVG.
- Missing the 20th birthday. From the following month, basic health insurance pays, with co-payment.
- Leaving out basic health insurance. Even with IV cover, the child needs basic health insurance for all other treatment.
Frequently asked questions
Who pays for the treatment of a congenital disorder?
Until the age of 20, invalidity insurance pays if the disorder is on the GgV-EDI list and meets the criteria of Art. 13 IVG. Otherwise, and after that, basic health insurance pays, with deductible and retention fee.
Do I have to register my child with invalidity insurance?
Yes. Invalidity insurance only pays if the child is registered with the IV office of the canton of residence. A doctor’s diagnosis alone is not enough; the IV office examines the entitlement and decides.
Does the health insurer pay for dental treatment for congenital disorders?
For certain congenital disorders, yes. Art. 19a KLV lists them. Basic health insurance pays for the dental treatment if it is needed after the age of 20 or if invalidity insurance is not responsible before that.
Does a congenital disorder affect supplementary insurance?
Possibly. Supplementary insurance is governed by the Insurance Contract Act (ICA); the insurer may ask health questions and impose a reservation. Some insurers accept children without a health check if the parents register them before birth; the conditions are in the general insurance conditions.
Related terms
- Invalidity insuranceInvalidity insurance (IV) is the compulsory social insurance for people whose ability to earn a living is permanently limited because of a congenital disorder, illness or accident. It first pays for integration measures and aids and appliances, and only then a pension from a degree of invalidity of 40%. For congenital disorders it covers treatment up to age 20, ahead of the health insurer.
- ChildbirthBasic health insurance covers the costs of childbirth, in hospital, in a birth centre or at home. For maternity benefits, you pay no deductible and no retention fee, and the same applies to treatment from the 13th week of pregnancy until 8 weeks after the birth. You must register your baby with a health insurer within 3 months.
- OrthodonticsOrthodontics corrects misaligned teeth and jaws, usually with braces. Basic health insurance only pays for it in exceptional cases: for a recognised congenital disorder, a serious disease of the masticatory system or after an accident. For congenital disorders up to the age of 20, invalidity insurance (IV) usually pays. Ordinary braces are only covered by supplementary insurance.
- Children’s premiumThe children’s premium is the monthly basic health insurance premium for children up to the age of 18. The law requires it to be lower than the premium for young adults and adults. In Bern, the 2026 median was CHF 145.90 a month with a CHF 0 deductible, compared with CHF 609.30 for adults with CHF 300 (FOPH).
Sources
- Federal Act on Disability Insurance (IVG), Art. 13 (German; the English version on fedlex predates the 2022 reform)Art. 13 IVGfedlex.admin.ch
- Invalidity Insurance Ordinance (IVV), Art. 3bis and 3ter (German; the English version on fedlex predates these articles)Art. 3ter IVVfedlex.admin.ch
- FDHA Ordinance on Congenital Disorders (GgV-EDI), annex (German, no English version)fedlex.admin.ch
- Federal Health Insurance Act (KVG), Art. 27Art. 27 KVGfedlex.admin.ch
- Federal Health Insurance Act (KVG), Art. 3, 5 and 64Art. 3 para. 1 KVGfedlex.admin.ch
- FOPH, health insurance premiums 2026 (opendata.swiss)opendata.swiss
- Health Care Benefits Ordinance (KLV), Art. 19aArt. 19a KLVfedlex.admin.ch
- Federal Act on the General Part of Social Insurance Law (ATSG), Art. 3 and 64Art. 3 para. 2 ATSGfedlex.admin.ch