Flex hospital insurance

What is flex hospital insurance?

Flex hospital insurance is a form of supplementary hospital insurance. With classic supplementary hospital insurance, you decide when you take out the policy which ward you want to stay in, for example semi-private. With a flex variant, you only decide this when a hospital stay is coming up. For the higher ward, you then pay an agreed share of the costs yourself.

The basic idea: you pay a lower premium than for fixed semi-private or private cover, and in return you bear part of the extra costs if it happens. If you want to stay in the general ward for a short procedure, you pay nothing extra. If you want to stay in a semi-private or private ward for a major operation, you choose the higher ward and take on the co-payment.

It is important to distinguish this from basic health insurance. Basic health insurance under the Federal Health Insurance Act (KVG) pays for the hospital stay at the standard of the general ward in a listed hospital. Anything beyond that, i.e. a two-bed or single room, free choice of doctor in hospital and often free choice of hospital throughout Switzerland, is only covered by supplementary insurance under the Insurance Contract Act (ICA). So “flex” is not a legal term but a type of product offered by insurers. Names and rules differ from insurer to insurer.

How it works

The mechanism is similar across flex products, but the figures are set out in the general terms and conditions (AVB) or supplementary conditions (ZB) of your product:

• Choose the ward: Before admission to hospital, you decide on general, semi-private or private.
• Obtain cost approval: For planned procedures, insurers often require cost approval for the hospital and ward before admission. In the CSS supplementary conditions for myFlex, for example, no costs are reimbursed for elective treatment without cost approval.
• Pay the co-payment: For the higher ward, you pay a percentage of the extra costs up to a cap, or a fixed amount. The general ward is usually free of any additional co-payment.
• Choose an option: Some products, such as myFlex with three categories, offer several options with different premiums and different levels of co-payment.

Two publicly available examples show the range. For “Hospital Flex”, Visana states a surcharge of CHF 2,000 for the semi-private ward and CHF 4,000 for the private ward; for “Hospital Flex Plus”, 20% of the costs, at most CHF 2,000 for semi-private, and 35%, at most CHF 4,000 for private. Depending on the category and option, the CSS supplementary conditions for myFlex state for the semi-private ward, for example, 40% up to CHF 8,000 or 20% up to CHF 2,000 per calendar year. These figures come from the insurers and can change; your policy and the current general terms and conditions always apply.

Legal basis

For flex hospital insurance there is no statutory rule on the choice of ward or the amount of the co-payment. These points are set by the insurer’s general terms and conditions.

The legal framework is formed by several acts. Art. 25 para. 2 let. e KVG provides that basic health insurance covers the hospital stay at the standard of the general ward. Under Art. 2 para. 2 of the Health Insurance Supervision Act (KVAG), health insurers may also offer supplementary insurance, which is subject to the Insurance Contract Act. The ICA governs the contract: Art. 35a para. 1 ICA allows ordinary cancellation at the end of the third or any subsequent year with three months’ notice, and under Art. 35a para. 4 ICA only you have this right of cancellation in supplementary health insurance, not the insurer. The insurer must submit the tariffs and general terms and conditions of supplementary insurance to social health insurance to FINMA (Art. 4 para. 2 let. r of the Insurance Supervision Act, ISA); FINMA checks the tariffs for solvency and protection against abuse (Art. 38 ISA).

Example: same procedure, two flex options

Daniel is 48 years old and has flex hospital insurance. For a planned operation he chooses the semi-private ward. The co-payments are taken from the CSS supplementary conditions for myFlex (option 1, categories “Economy” and “Balance”). The extra costs of the semi-private ward are an assumed amount, because they depend on the hospital and the procedure and are not published.

Whether the cheaper category is worth it depends on the premium difference. These premiums are not officially published; you find them out from the insurer’s quote.

What this means for you

Flex hospital insurance suits you if you want freedom of choice in hospital but do not want to pay the full semi-private premium for every stay. Check before you sign up:

1. What is your maximum co-payment? Work out what a stay would cost you in the worst case for semi-private and private, per stay or per year.
2. Which hospitals are covered? Check in the general terms and conditions whether the product covers all hospitals in Switzerland or only certain ones, such as hospitals with a contract.
3. Which deadlines apply? Read the waiting periods, for example for maternity, and the minimum term of the contract in the general terms and conditions.
4. What about your health? If you have pre-existing conditions, you will not always get supplementary insurance, or only with a reservation. Only cancel existing hospital insurance once the new one has been confirmed in writing.

You can compare the benefits of supplementary hospital insurance in the supplementary insurance comparison. The insurers that offer such products are listed under health insurers, for example in the profile of CSS or Visana. For basic health insurance, which you can take out with any insurer independently of this, the premium calculator will help.

Common mistakes

• Confusing flex with basic health insurance. The choice of ward only exists in supplementary insurance; basic health insurance covers the general ward.
• Forgetting the cost approval. Without approval before a planned admission, the supplementary insurance can refuse to pay.
• Comparing only the premium. What matters is the total of the annual premium and the possible co-payment for a stay.
• Answering the health questions incompletely. A breach of the duty of disclosure allows the insurer to cancel and can cost you benefits.
• Cancelling the old cover too early. Switching supplementary insurance is only possible with a new health check.