Cost estimate

What is a cost estimate?

A cost estimate (Kostenvoranschlag) is a written estimate of the costs of a planned treatment. It shows which services are planned, at which tariff they will be billed and what amount is likely to be charged. It is drawn up by the service provider, in other words the dentist, the orthodontist, the clinic or the therapist.

In health insurance, the cost estimate has a dual purpose. It shows you what to expect, and it is the basis for cost approval. Cost approval is the insurer’s commitment to cover the treatment in full or in part. The two terms are often confused: the estimate comes from the practice, the approval from the insurer.

You most often need a cost estimate at the dentist. Basic health insurance only covers dental costs in a few cases listed in the law. You pay for everything else yourself or through dental insurance. For braces for children, in other words orthodontics, supplementary insurance usually also requires a cost estimate before treatment begins.

No cost estimate is needed for the usual benefits of basic health insurance, such as a visit to the doctor or physiotherapy on prescription. These benefits and their tariffs are set out in the law and in tariff agreements.

How it works

The procedure is similar for basic and supplementary insurance:

1. Assessment. The practice examines you and draws up a treatment plan.
2. Cost estimate. The practice estimates the costs according to the applicable tariff, usually broken down by item.
3. Request to the insurer. You or the practice send the cost estimate to the insurer with a report. For basic health insurance, the insurer’s medical adviser often reviews the case.
4. Cost approval. The insurer tells you in writing whether and to what extent it will pay. If it refuses, you can request a written decision that can be challenged in basic health insurance.
5. Treatment and invoice. Only then does treatment begin. The invoice goes to you or directly to the insurer.

Tariff protection applies in basic health insurance. Service providers must comply with the tariffs set by contract or by the authorities and may not charge anything beyond them for KVG benefits. The cost estimate does not change this; it only makes visible which tariff items are planned. Outside basic health insurance, for example for normal dental treatment, the practice’s own prices apply. There, the cost estimate helps you compare.

Legal basis

The Federal Health Insurance Act (KVG) does not contain a general “cost estimate”. What matters are the rules on tariffs, the obligation to pay and cost approval:

• Art. 44 para. 1 KVG: tariff protection. Service providers comply with the tariffs and prices that have been set and do not charge any further remuneration for KVG benefits.
• Art. 31 para. 1 KVG: basic health insurance only covers dental treatment if it is caused by a serious, unavoidable disease of the masticatory system or by a serious general illness, or is necessary to treat one. Para. 2 adds damage caused by an accident if no accident insurer pays.
• Art. 17–19 KLV: the list of these illnesses. Under Art. 18 para. 2 KLV, the insurer only pays for dental treatment for serious general illnesses with prior special approval, taking into account the recommendation of its medical adviser.
• Art. 64 KVG and Art. 103 KVV: on basic health insurance benefits, you pay the deductible and a 10% retention fee, with a maximum retention fee of CHF 700 a year for adults.
• Art. 49 and 51 ATSG: if the insurer refuses a basic health insurance benefit and you disagree, you can request a written decision, against which you can lodge an objection.

Private law applies to services outside basic health insurance. For contracts for work and services, the Swiss Code of Obligations (CO) governs what applies if an approximate estimate is exceeded disproportionately through no fault of your own: you may then withdraw from the contract (Art. 375 para. 1 CO). Whether this rule fits a specific treatment depends on the contract with the practice. For supplementary insurance, the insurance terms determine when a cost estimate and cost approval are required.

Example: dental treatment with cost approval

Nora is 52. Because of a serious general illness, she needs dental treatment that falls under Art. 18 KLV. The dentist draws up a cost estimate of CHF 2,400 (assumption for the example) and sends it with a report to Nora’s insurer. After review by the medical adviser, the insurer grants cost approval. The table shows what Nora pays herself if she has no other costs during the year. The calculation uses the statutory values for the deductible and retention fee; the premium is not included.

What this means for you

Before any major treatment that is not one of the usual benefits of basic health insurance, get a written cost estimate. This is how to proceed:

1. Clarify who is responsible. Accident, basic health insurance or supplementary insurance? After an accident, the accident insurer usually pays; for dental treatment without a serious illness, usually no one does except dental insurance.
2. Send the cost estimate to the insurer. Ask in writing which part it will cover. Keep the reply and the estimate, for example in your account.
3. Compare for private services. Where the practice sets its own prices, a second cost estimate is worthwhile.
4. Bear your deductible in mind. Cost approval does not mean the insurer pays everything. Allow for the deductible and retention fee; you can see the effect of your deductible on the premium in the premium calculator.

Which supplementary insurance policies include which benefits is shown in the profiles of the health insurers. If the insurer refuses cost approval and you are unsure, you can request advice.

Common mistakes

• Taking the cost estimate for a commitment. It is the practice’s estimate. Only the insurer’s cost approval is binding on the insurer.
• Starting treatment before the insurer replies. If the law or the policy requires prior approval, you risk paying for everything yourself.
• Forgetting the deductible. Even with cost approval, you bear the deductible and retention fee.
• Not reporting changes. If the treatment plan changes, the cost approval no longer fits. Have a new cost estimate drawn up.
• Settling for verbal information. Always keep the cost estimate and cost approval in writing.

How we handle examples and tariffs is explained under how we calculate.