Reimbursement

What is reimbursement?

In health insurance, reimbursement means that your health insurer pays you back money you paid in advance for insured treatment. This happens when the doctor, therapist or laboratory sends the bill directly to you and you pay it. This procedure is called tiers garant: you owe the service provider the payment, and the insurer owes you the reimbursement.

The counterpart is tiers payant. There, the service provider bills the insurer directly, and the insurer claims your share back from you with the statement of benefits. The reimbursement claim form, by contrast, only exists in tiers garant: with it, you claim money back from the insurer yourself. In both cases, you end up paying the same share. The only difference is who pays the money in advance.

Reimbursement mainly concerns basic health insurance, but applies by analogy to supplementary insurance as well. There, the contract determines which costs the insurer pays back and how much. It does not refer to the premium refund, which concerns premiums paid in excess.

How it works

1. Receive and pay the bill. The doctor’s bill comes to you. You pay it within the deadline stated on the bill.
2. Submit the bill. You send the bill to your insurer, via the app, customer portal or by post. You do not need a special form for this. Keep a copy.
3. Review by the insurer. The insurer checks whether the benefit is insured and the tariff is correct, and calculates your co-payment.
4. Statement of benefits and payment. You receive a statement of benefits. If the total of your bills is above the deductible, the insurer transfers the amount minus the retention fee to your account.

The insurer calculates in this order: first, the bill goes towards your annual deductible, then it deducts the 10% retention fee until the maximum amount of CHF 700 for adults or CHF 350 for children is reached. You get back what remains. The date of treatment is what counts. A bill for treatment in December therefore belongs to the old year, even if you only submit it in January.

In tiers garant, you may assign your entitlement to reimbursement to the service provider. The insurer then pays the practice directly. This can make sense if you cannot pay a large bill in advance; ask the practice about it.

Legal basis

Art. 42 para. 1 of the Federal Health Insurance Act (KVG) stipulates: unless the insurer and service provider have agreed otherwise, you owe the service provider the payment and are entitled to reimbursement from the insurer. You can assign this entitlement to the service provider. Under Art. 42 para. 3 KVG, the service provider must send you a detailed and comprehensible bill. Art. 42 para. 6 KVG states that no form is required to register a claim for benefits.

How much the insurer deducts is determined by Art. 64 para. 2 KVG (deductible and 10% retention fee) and Art. 103 of the Health Insurance Ordinance (KVV) (standard deductible of CHF 300, maximum retention fee of CHF 700 for adults and CHF 350 for children, date of treatment decisive). The deadline is set out in Art. 24 para. 1 of the Federal Act on the General Part of Social Insurance Law (ATSG): five years after the end of the month for which the benefit was owed. If the insurer refuses a reimbursement and you disagree, it must issue a written decision under Art. 49 para. 1 ATSG. Under Art. 52 para. 1 ATSG, you can lodge an objection against it within 30 days; the procedure is free of charge.

Example: three bills under tiers garant

Sara is 41 years old and has a deductible of CHF 500. She pays three doctor’s bills herself and submits them. The bill amounts are chosen freely; the deductible and retention fee follow the law.

What this means for you

Submit every bill, even if you have not yet reached your deductible. That is the only way your insurer knows when the deductible has been used up. Practical tips:

1. Submit straight away. Bills are easily lost. With your insurer’s app, you photograph them right after paying.
2. Check the statement of benefits. Are the deductible and retention fee correct? Is a bill missing? Report discrepancies in writing.
3. Request a written decision if your claim is refused. You can only lodge an objection against a written decision. The Office of the health insurance ombudsperson mediates free of charge.
4. Do not pay large bills in advance. Ask the practice whether it bills the insurer directly or whether you can assign the entitlement.

If you exceed your deductible every year, a different deductible may be worthwhile. In the premium calculator, you compare the premiums of all insurers for every deductible. You can find the insurers’ key figures under Health insurers. You can save the results of our tools in your account.

Common mistakes

• Keeping small bills. If you do not submit bills below the deductible, you will get less back later.
• Not paying the bill because the insurer pays. Under tiers garant, you owe the service provider the amount, even if the reimbursement is still outstanding.
• Missing deadlines. After five years, the entitlement expires.
• Mixing up supplementary and basic health insurance. For benefits from supplementary insurance, the rules of your contract apply, including deadlines.

We explain how we build examples under How we calculate.