Supplementary outpatient insurance

What is supplementary outpatient insurance?

Supplementary outpatient insurance complements basic health insurance for treatment without a hospital stay. It pays for services that are missing from the benefits covered by basic health insurance or are limited there. Typical examples are contributions towards glasses and contact lenses for adults, towards complementary medicine provided by non-medical therapists, towards medicines outside the List of Pharmaceutical Specialties, towards transport and rescue costs beyond the statutory contribution, towards prevention and fitness, and towards treatment abroad.

It is one of several types of supplementary insurance. It must be distinguished from supplementary hospital insurance, which covers inpatient stays in the semi-private or private ward, and from dental insurance, which helps pay for check-ups and treatment at the dentist. Many insurers bundle several modules into one product; product names are not standardised.

Legally, supplementary outpatient insurance is a private contract under the Insurance Contract Act (ICA). This sets it fundamentally apart from basic health insurance under the Federal Health Insurance Act (KVG): there is no obligation to accept you, no statutory uniform benefits and no uniform premiums per region approved by the FOPH. Supervision is carried out by FINMA.

How it works

Taking it out. You submit an application and answer health questions. The insurer can accept you, accept you with a reservation for certain conditions, or turn you down. The premium depends on the product, your age and often where you live. Before the contract is concluded, the insurer must inform you about the insured risks, the scope of cover, the premium and the term.

Benefits. Depending on the service, the insurer pays a percentage of the costs, a fixed amount or both, up to a maximum per year or per period. Examples are the contribution towards glasses every few years or the fitness contribution per year. Some benefits require a doctor’s prescription or a recognised therapist.

Claims. You submit bills in the same way as for basic health insurance. The insurer first checks whether basic health insurance pays. Only what is not covered there is settled through the supplementary insurance. A contractual excess is possible but has nothing to do with the statutory deductible.

Cancellation. The contract often runs for several years. You can cancel it for the end of the third or any subsequent year if the contract does not provide for a shorter period. The insurer itself may not give ordinary notice in supplementary health insurance.

Legal basis

There is no statutory list of benefits. The basis consists of:

• Art. 2 para. 2 KVAG: Health insurers may offer supplementary insurance alongside basic health insurance; this is governed by the ICA.
• Art. 64 para. 8 KVG: Co-payments in basic health insurance, i.e. the deductible and retention fee, may not be insured either with a health insurer or with a private insurance company.
• Art. 7 para. 7 and 8 KVG: When you switch your basic health insurance, your previous insurer may neither force you to cancel your supplementary insurance nor cancel it for that reason alone.
• Art. 2a ICA: Right of revocation of 14 days from application or acceptance.
• Art. 3 ICA: The insurer’s duty to provide information before the contract is concluded.
• Art. 4 and 6 ICA: You must answer the health questions truthfully. If you conceal a material fact, the insurer may cancel the contract within four weeks of becoming aware of it.
• Art. 35a para. 1 and 4 ICA: Ordinary notice for the end of the third or any subsequent year with three months’ notice; in supplementary health insurance, only you have this right.

Example: what the supplementary insurance pays and what it does not

Mia is 33, has the CHF 2,500 deductible and a supplementary outpatient insurance. She has three expenses in the same year. The amounts and the values of her contract are fictitious; the allocation follows the law.

What this means for you

Only take out supplementary outpatient insurance if you are likely to use its benefits. These questions help you:

1. Which services do you need regularly? Glasses, complementary medicine, certain medicines or frequent travel tend to speak in favour of supplementary insurance.
2. How high is the premium compared with the contributions? Compare the annual premium with realistic reimbursements.
3. How healthy are you today? With pre-existing conditions, reservations or rejections become more likely. If you want supplementary insurance, it is better to take it out early.
4. Never cancel first. If you want to change your supplementary insurance, only cancel the old contract once the new insurer has accepted you in writing.

You choose your basic health insurance independently of this. In the premium calculator you can compare the basic premiums of all insurers using the official FOPH data, under health insurers you will find their key figures, and under switching insurer the steps of a switch. We set out the supplementary benefits side by side under compare supplementary insurance; the needs check helps you assess what you need.

Common mistakes

• Trying to use the supplementary insurance for the deductible. No insurance may take over the deductible and retention fee of basic health insurance.
• Cancelling basic and supplementary insurance together. When you switch your basic health insurance, you can keep your supplementary insurance. If you cancel both, you may lose it for good.
• Answering health questions incompletely. In the event of a breach of the duty of disclosure, the insurer may cancel the contract and refuse benefits.
• Overlooking the minimum term. Many contracts can only be cancelled with ordinary notice after three years.

We explain how we build our comparisons under How we calculate.