Medical adviser

What is a medical adviser?

The medical adviser of the insurer (Vertrauensarzt or Vertrauensärztin in German) is an experienced doctor who advises a health insurer on medical questions. The adviser checks whether a treatment meets the conditions under which basic health insurance must pay for it. The central question is whether a benefit is effective, appropriate and cost-effective, in short the effectiveness, appropriateness and cost-effectiveness criteria.

The German name, which literally means “doctor of trust”, says a lot about the role: the medical adviser stands between you, your treating doctor and the insurer’s administration. The adviser receives medical information that the claims staff are not supposed to see, and decides independently. The law expressly protects this position: neither the insurer nor doctors, hospitals or their associations may give the adviser instructions.

Medical advisers exist in basic health insurance under the Federal Health Insurance Act (KVG). Insurers also work with medical advisers in supplementary insurance, but there the rules of the Insurance Contract Act (ICA) and of the contract apply, not Art. 57 KVG. The medical adviser is also not the same as case management, which supports insured persons through long or complex cases of illness.

Anyone who wants to become a medical adviser must meet the requirements for admission as a doctor under basic health insurance and have worked for at least five years in a medical practice or in a senior position in a hospital. The insurer appoints the adviser after consulting the cantonal medical association, which can reject the person for important reasons.

How it works

When the medical adviser becomes involved

Most invoices are processed without the medical adviser. The adviser is called in when the law requires it or the insurer needs to clarify a medical question. Typical cases:

• Cost approvals: the insurer only pays for certain benefits after giving prior approval. The medical adviser reviews the treating doctor’s request. More on this under cost approval.
• Longer therapies: the Health Care Benefits Ordinance (KLV) requires reports to the medical adviser, for example for physiotherapy after 36 sessions, for psychotherapy provided by a doctor after 40 sessions and for nutritional advice or diabetes counselling after a certain number of sessions.
• Nursing care: if the needs assessment provides for more than 60 hours of care per quarter, the medical adviser can review it; for fewer hours, the adviser carries out spot checks.
• Procedures that should be outpatient: if a procedure from the list in Annex 1a KLV is to be carried out on an inpatient basis for reasons other than those listed there, a special approval from the insurer is required, which takes into account the medical adviser’s recommendation.
• Unclear invoices: the insurer can request additional medical information in order to understand the diagnosis and treatment.

How the adviser decides

The medical adviser reviews the documents that the treating doctor must provide. If they are not sufficient, the adviser can examine you personally, but must notify your doctor beforehand and inform them afterwards. In justified cases, you can ask to be examined by another doctor. If you and the insurer cannot agree on this, the cantonal arbitration tribunal decides.

Formally, it is not the medical adviser but the insurer that decides. The adviser makes a recommendation or a proposal, for example on whether and for how long a therapy will continue to be paid for. The insurer informs you of the decision.

What the adviser passes on

The medical adviser only passes on to the insurer the information it needs to decide on its obligation to pay, to set the remuneration, to calculate risk equalisation or to give reasons for a written decision. In doing so, the adviser protects your personal rights. You can also ask your doctor to send medical information only to the adviser and not to the benefits department. More on protecting your data under data protection.

Legal basis

The key provision is Art. 57 KVG:

• Paras. 1–3: insurers or their associations appoint medical advisers after consulting the cantonal medical associations. Advisers must meet the admission requirements and have worked for at least five years in a practice or in a senior hospital position. A medical association can reject a person for important reasons.
• Para. 4: medical advisers advise the insurer on specialist medical questions and on questions of remuneration and the application of tariffs, and review whether the conditions for the obligation to pay are met.
• Para. 5: they are independent in their judgement; no one can give them instructions.
• Para. 6: service providers must provide them with the necessary information. Personal examinations are possible if the information cannot be obtained in any other way; insured persons can ask for another doctor in justified cases.
• Para. 7: information is only passed on to the insurer to the extent necessary for the decision on benefits, remuneration, risk equalisation or a written decision.

Further provisions: under Art. 42 para. 5 KVG, the treating doctor is entitled in justified cases, and obliged at your request, to disclose medical information only to the medical adviser. The KLV names specific occasions: Art. 3b (psychotherapy after 40 sessions, decision within 15 working days), Art. 5 para. 4 (physiotherapy after 36 sessions), Art. 8c (review of nursing care of 60 hours or more per quarter) and Art. 3c para. 3 (special approval for certain inpatient procedures). The yardstick is Art. 32 KVG: effective, appropriate and cost-effective.

Example: psychotherapy beyond 40 sessions

Laura is 33 and has been in psychotherapy with a doctor once a week since Monday, 12.01.2026. Basic health insurance covers the costs. With weekly sessions, the 40th session takes place on Monday, 12.10.2026. If the therapy is to continue after that, the psychiatrist must report to the medical adviser in good time.

Physiotherapy works in a similar way: the insurer covers a maximum of nine sessions per medical prescription. After four prescriptions, i.e. 36 sessions, continuing requires a report to the medical adviser.

What this means for you

For you, the medical adviser is a safeguard for your health data and at the same time the body that helps decide sensitive questions about benefits. Use both deliberately:

1. Decide where your data goes. If you do not want diagnoses to end up with the claims staff, tell your doctor to send medical information only to the medical adviser.
2. Keep an eye on deadlines. For longer therapies, ask early when the report is due, so that there is no gap in cost coverage.
3. Obtain cost approval in advance. For expensive or special treatments, have your doctor submit a request before treatment begins.
4. Ask for a written decision if you are turned down. You are entitled to a decision that can be challenged. The Office of the health insurance ombudsperson offers advice.

The statutory benefits and the role of the medical adviser are the same with all insurers. Differences exist in service and availability; the profiles under health insurers show key figures for each insurer. Compare premiums in the premium calculator.

Common mistakes

• Seeing the medical adviser as an opponent. The adviser is independent and assesses cases according to statutory criteria. A well-reasoned request from your doctor has a good chance of success.
• Continuing therapy without a report. If you continue after 36 sessions of physiotherapy or 40 sessions of psychotherapy without a report, you risk paying the costs yourself.
• Letting diagnoses be sent to the insurer even though you do not want this. You can insist that they go through the medical adviser.
• Accepting a verbal rejection. Ask for written reasons and, if necessary, a written decision.
• Mixing up the medical adviser and supplementary insurance. Art. 57 KVG applies to basic health insurance; for supplementary insurance, the contract terms apply.

We explain how we check legal sources for these pages under How we calculate.