Statement of benefits

What is the statement of benefits?

The statement of benefits is the notice from your health insurer that it has processed one or more bills from doctors, pharmacies, hospitals or therapists. It lists each treatment with its date and amount and shows which part is charged to the insurer and which part remains with you. In basic health insurance, your part is made up of the deductible and the retention fee, and for a hospital stay possibly also the contribution towards the cost of the stay.

Depending on how the bill was settled, the statement of benefits has a different function. If you paid the bill yourself and submitted it, it shows you how much the insurer will reimburse. If the insurer paid the bill directly to the service provider, it uses the statement to claim your share from you. Some insurers then call it a “reclaim” or a “co-payment invoice”. Do not confuse it with the reimbursement claim form: that is the copy of the bill that you send to the insurer yourself under tiers garant.

The statement of benefits mainly concerns basic health insurance under the Federal Health Insurance Act (KVG). If you have supplementary insurance, the insurer often lists its benefits on the same letter in a separate section. For supplementary insurance, however, the rules of your contract apply, not the deductible and retention fee of the KVG.

How it works

A bill reaches the insurer in one of two ways. Under tiers garant, you owe the doctor the amount on the bill, pay it and submit it to the insurer. Under tiers payant, the service provider sends the bill directly to the insurer, and you receive a copy. Pharmacies and hospitals usually bill the insurer directly, while many doctors’ practices use tiers garant.

The insurer then checks three things: Is the benefit covered by basic health insurance? Is the tariff correct? And how much of your deductible have you already used this year? Only then does it calculate your share. As long as you have not reached your deductible, you bear the full amount of the bill yourself. After that, you pay 10% of the costs until you reach the annual maximum retention fee: CHF 700 for adults and CHF 350 for children. There is no standard deductible for children.

A typical statement of benefits contains this information:

Because the date of treatment counts, a statement in February can still relate to the previous year. A treatment in December is then charged to the old year’s deductible, even if you pay it in the new year.

Legal basis

Art. 42 para. 1 KVG governs tiers garant: the insured person owes the service provider the payment and is entitled to reimbursement from the insurer. Under Art. 42 para. 2 KVG, insurers and service providers can agree on tiers payant. Art. 42 para. 3 KVG requires a detailed and comprehensible bill; under tiers payant, the service provider must send you a copy without being asked. Under Art. 42 para. 3ter KVG, you receive the bill on paper free of charge if you ask for it.

Art. 59 KVV lists what a bill must contain, including the dates of the treatments and the services provided. Art. 59 para. 2 KVV requires separate bills for compulsory benefits and other benefits. The co-payment itself is set out in Art. 64 para. 2 KVG (deductible and 10% retention fee), and the amounts in Art. 103 KVV. Under Art. 103 para. 3 KVV, the date of treatment is decisive. Art. 24 para. 1 ATSG sets the deadline: the right to outstanding benefits expires five years after the end of the month for which the benefit was owed.

Example: three bills in the same year

Laura is 29, has the standard deductible of CHF 300 and has not had any costs yet this year. In March, she receives a statement of benefits covering three bills. The example uses the statutory amounts; the invoice amounts are chosen freely.

What this means for you

Read each statement of benefits briefly before you pay it. Three questions are usually enough:

1. Do you recognise the treatment? Report any treatment you do not recognise to the insurer. To do this, compare the statement with the copy of the invoice.
2. Is the deductible correct? If you have already reached your deductible this year, the insurer may not charge you any more deductible. If you switched insurer during the year, the new insurer counts the deductible you have already paid (Art. 103 para. 4 KVV).
3. Is anything “not insured”? Ask why. Often this concerns benefits without a doctor’s prescription or benefits that only supplementary insurance covers.

Keep the statements at least until your next tax return. The insurer’s annual overview, the tax certificate, summarises your co-payments. If you want to collect results from our tools, you can save them in your account.

If you find that you never reach your deductible, or go far beyond it every year, it is worth looking at premiums: in the premium calculator, you can compare all insurers with the official FOPH data for every deductible. You can find the insurers and their key figures under health insurers, and how switching works under switch insurer.

Common mistakes

• Not submitting bills. Amounts below the deductible also belong with the insurer. Only then are they counted, and the insurer pays as soon as the deductible has been reached.
• Paying twice. If the insurer has already paid a bill directly, you only pay the share on the statement of benefits, not the doctor’s bill.
• Confusing the statement with the premium invoice. You pay the premium every month. The statement of benefits only concerns costs from treatment.
• Missing deadlines. Submit old bills within five years at the latest. After that, the right expires.

We explain how we build examples and calculators under how we calculate.