Dental costs

What are dental costs?

Dental costs are all the costs of examinations and treatments of teeth, gums and jaw: check-ups, dental hygiene, fillings, root canal treatments, crowns, bridges, implants, braces and surgical procedures. In health insurance, the question is who bears these costs.

In Switzerland the answer is different from most other benefits: in principle, you pay the dentist yourself. Basic health insurance under the Health Insurance Act (KVG) only covers dental treatment in an exhaustive list of cases. The idea behind this is that tooth decay and gum inflammation can usually be avoided through care and prevention.

If you want more cover, you can take out dental insurance. This is voluntary supplementary insurance under the Insurance Contract Act (ICA). There, the insurer may ask health questions, reject applications and impose reservations, and it decides itself what share of the bill it pays and up to what annual amount.

Dental costs also have a special feature when it comes to billing: dentists usually send the bill directly to you. If an insurer covers part of it, you submit the bill to that insurer. Before larger work, you can ask for a cost estimate.

How it works

Basic health insurance: It only pays for dental treatment in four groups of cases (Art. 31 KVG):

1. Severe, unavoidable diseases of the masticatory system (Art. 17 KLV), for example certain tumours in the jaw area, osteoarthritis of the jaw joint, cysts or dysgnathia with sleep apnoea. The condition must amount to an illness.
2. Severe general illnesses and their consequences (Art. 18 KLV), for example leukaemia, severe diseases of the blood system, certain metabolic disorders or severe mental illnesses with severe impairment of the chewing function. Here, special prior approval from the insurer is required.
3. Dental treatment in support of medical treatment (Art. 19 KLV), for example before a heart valve replacement, during radiotherapy or chemotherapy, or for sleep apnoea.
4. Certain congenital disorders (Art. 19a KLV), for example cleft lip, jaw and palate, if disability insurance does not pay.

In addition there are accidents: basic health insurance covers damage to the masticatory system after an accident if no accident insurance pays (Art. 31 para. 2 KVG). If you are employed, your employer’s accident insurance usually pays.

If basic health insurance covers a dental treatment, the deductible and retention fee apply as for any other benefit.

Dental insurance: For check-ups, dental hygiene, fillings, crowns and braces, there is only voluntary supplementary insurance. Many products require you to take them out before any need for treatment is known. For children this means: if you want to cover orthodontics later on, you have to take out insurance early.

Supplementary benefits: If you receive annual supplementary benefits to old-age and survivors’ insurance or disability insurance, the canton reimburses you for documented costs of dental treatment (Art. 14 para. 1 let. a ELG). The cantons may limit reimbursement to cost-effective and appropriate treatment.

Legal basis

Art. 31 para. 1 KVG states that basic health insurance only covers the costs of dental treatment if it is caused by a severe, unavoidable disease of the masticatory system (let. a) or by a severe general illness or its consequences (let. b), or is necessary for the treatment of a severe general illness (let. c). Para. 2 adds the treatment of accident damage to the masticatory system.

Exactly which diseases are meant is listed exhaustively in Art. 17 to 19a of the Health Care Benefits Ordinance (KLV). For general illnesses, Art. 18 para. 2 KLV requires special prior approval from the insurer, which takes into account the recommendation of its medical adviser. Art. 19a KLV lists the congenital disorders and applies to treatment after the age of 20, or earlier for people who are not insured with disability insurance.

There is no statutory obligation to pay benefits for dental insurance. Scope, reimbursement rate and annual limit are set out in the insurer’s general terms and conditions; the Insurance Contract Act (ICA) applies.

Example: two dentist’s bills, two routes

Petra is 58, has the standard deductible of CHF 300 and no other costs so far this year. She receives two bills. The amounts are assumed; the deductible and retention fee are the statutory values.

Whether dental insurance is worthwhile depends on how high the premium is compared with the expected reimbursement. For children who may need braces, the calculation is often different from that for adults with healthy teeth.

What this means for you

• Include dental costs in your budget. Check-ups and dental hygiene come up regularly. For larger work, ask for a cost estimate.
• Check whether an exceptional case applies. If chemotherapy, a heart valve replacement or a procedure with long-term immunosuppression is coming up, ask your doctor whether dental restoration is needed beforehand. In that case basic health insurance may pay.
• Report accidents immediately. A broken tooth after a fall is an accident. Report it to your employer or your insurer before you start treatment.
• Compare dental insurance early. Especially for children, it pays to take out insurance before any treatment is foreseeable. You can compare the offers under compare supplementary insurance; the health insurers overview shows which insurer has which products.
• Optimise basic health insurance separately. Basic health insurance rarely pays the dentist. Save there through your deductible and insurance model in the premium calculator.
• Remember supplementary benefits. If you receive them, submit dentist’s bills to the canton. Read more under supplementary benefits.

Common mistakes

• Believing basic health insurance pays for fillings. Tooth decay and its consequences are considered avoidable and are not insured.
• Taking out dental insurance too late. If a need for treatment is already known, many insurers exclude it or reject the application.
• Not reporting dental accidents. Without an accident report, the accident insurer cannot examine the case, and you may be left with the bill.
• Forgetting prior approval. For general illnesses, basic health insurance only pays if the insurer has agreed in advance (Art. 18 para. 2 KLV).

We explain how we build our examples under How we calculate.