Orthodontics

What is orthodontics?

Orthodontics is the branch of dentistry that identifies and treats misaligned teeth and jaws. Typical treatments are fixed braces (brackets), removable braces, clear aligners and, in severe cases, a combination with jaw surgery. Most treatments take place in childhood and adolescence, because the jaws and teeth are still growing then.

In health insurance, orthodontics is part of dental treatment. And for dental treatment, one principle applies: basic health insurance generally does not pay for it. It only covers it in three cases that the law lists exhaustively: for serious, unavoidable diseases of the masticatory system, for serious general illnesses and after an accident if no accident insurance pays. You can read more about other dental treatments under dental costs.

For children there is a fourth body: invalidity insurance (IV). Up to the age of 20, it is responsible for the treatment of congenital disorders, including severe congenital jaw misalignments.

Most braces fall into none of these categories. Parents pay for minor misalignments, crowding or a correction for aesthetic reasons themselves, or a dental insurance pays as supplementary insurance.

How it works

Who pays depends on the cause, the severity and the age. The assessment follows this order:

1. Congenital disorder and under 20: if there is a congenital disorder that has been diagnosed by a specialist, reaches a certain degree of severity and requires long-term or complex treatment, IV is responsible. You register with the IV office.
2. Congenital disorder, but IV not responsible: basic health insurance pays if the congenital disorder is on the list in Art. 19a of the Health Care Benefits Ordinance (KLV) and treatment is needed after the age of 20 or the person is not insured with IV. The list includes, among other things, cleft lip, jaw and palate and congenital jaw misalignments that reach certain measured values set out in the KLV.
3. Serious disease of the masticatory system: basic health insurance pays for jaw misalignments (dysgnathia) if they lead to sleep apnoea, severe swallowing disorders or severe craniofacial asymmetries. The condition must amount to an illness; only what this illness makes necessary is paid for.
4. Accident: damage to the masticatory system caused by an accident is paid for first by accident insurance, otherwise by the accident cover of basic health insurance.
5. All other cases: supplementary insurance, if you have it, otherwise you pay yourself.

In the cases covered by basic health insurance, the normal co-payment applies. For children up to 18 there is no standard deductible, but a 10% retention fee up to a maximum of CHF 350 per year. Adults pay the deductible and a retention fee up to CHF 700.

Supplementary insurance for teeth or orthodontics works according to the contract, for example with a percentage of the costs and a maximum amount per year or per treatment. Before you sign up, the insurer may ask health questions and exclude known findings.

Legal basis

Art. 31 of the Federal Health Insurance Act (KVG) is the central provision: basic health insurance covers the costs of dental treatment if it is caused by a serious, unavoidable disease of the masticatory system (para. 1 let. a), by a serious general illness or its consequences (let. b), or is necessary to treat a serious general illness (let. c). Under para. 2, it also pays for damage to the masticatory system caused by an accident.

The Health Care Benefits Ordinance (KLV) sets out the details:

• Art. 17 KLV: list of serious diseases of the masticatory system. Let. f covers dysgnathia that leads to sleep apnoea syndrome, severe swallowing disorders or severe craniofacial asymmetries. The condition must amount to an illness.
• Art. 18 KLV: dental treatment because of serious general illnesses, only with prior special approval by the insurer on the recommendation of its medical adviser.
• Art. 19a KLV: dental treatment for certain congenital disorders if it is needed after the age of 20 or the person is not insured with IV. The list includes, among other things, cleft lip, jaw and palate (no. 13) and congenital jaw misalignments with defined measured values, for example with a retruded lower jaw or an open bite (nos. 20–22).

For children and young people, Art. 13 of the Federal Act on Invalidity Insurance (IVG) takes precedence: up to the age of 20, insured persons are entitled to medical measures for the treatment of congenital disorders that have been diagnosed by a specialist, impair health, reach a certain degree of severity and require long-term or complex treatment.

The co-payment in basic health insurance is governed by Art. 64 KVG and Art. 103 of the Health Insurance Ordinance (KVV): children have no standard deductible and pay at most CHF 350 retention fee per year, adults at most CHF 700. There is no statutory obligation to pay benefits for supplementary insurance; the contract under the Insurance Contract Act (ICA) is decisive.

Example: the same braces, three situations

For all three cases we assume treatment costs of CHF 6,000; this is a figure for the calculation, not a tariff. The children have the standard children’s deductible of CHF 0, the adult a deductible of CHF 300 and no other costs so far this year.

What this means for you

• Get it checked early: have misalignments in children examined early. For severe, congenital forms, registering with IV comes first.
• Ask for a cost estimate: a cost estimate shows the costs and is the basis for the cost approval by IV, basic or supplementary insurance.
• Take out supplementary insurance in good time: dental insurance for your child only helps if it is taken out before a finding is known. You can compare benefits and limits under compare supplementary insurance.
• Premiums for your child: you can compare the basic health insurance premium for children in the children’s premium calculator or in the premium calculator. Which insurers offer which supplementary insurance is shown under health insurers.

Common mistakes

• Assuming basic health insurance pays for braces. Only in the exceptions named by law. Most braces are a private matter or a matter for supplementary insurance.
• Forgetting IV. For severe, congenital misalignments, IV is responsible up to the age of 20, not the health insurer.
• Taking out dental insurance too late. Once a finding is known, the insurer can exclude it.
• Starting without a cost approval. If you begin treatment before IV or the insurer has given its approval, you risk bearing part of the cost yourself.

We explain how we make the benefits of supplementary insurance comparable under How we calculate. You can read more about the premium for your child under children’s premium.