Written decision

What is a written decision?

A written decision is a formal decision by a social insurer on your rights and obligations. In health insurance, the health insurer issues written decisions for basic health insurance under the Federal Health Insurance Act (KVG). The written decision lays down with binding effect what applies: whether a benefit is paid, whether you have to repay an amount or whether a premium claim exists.

What makes a written decision special is its effect. It can be contested, and if you do not contest it, it becomes legally binding. That is why the law prescribes what it must look like: in writing, with information on how to appeal and, if it does not fully meet your request, with reasons. The procedure is governed by the ATSG, which under Art. 1 KVG also applies to health insurance.

A written decision must be distinguished from three other types of letter:

• Statement of benefits: It shows what the health insurer pays and what you bear yourself. It is an informal decision and not a written decision.
• Premium invoice and reminder: These are not written decisions either. Only if the health insurer wants to enforce a claim and you lodge an objection to the debt enforcement does it come to a written decision.
• Letters about supplementary insurance: Supplementary insurance is subject to the Insurance Contract Act (ICA). There are no written decisions there, only contractual statements.

How it works

In basic health insurance, the health insurer pays benefits in the informal procedure (Art. 51 ATSG). The KVG goes further than other social insurance schemes: even substantial benefits are granted informally (Art. 80 para. 1 KVG). As long as you agree, you therefore do not receive a written decision.

The health insurer issues a written decision if:

1. you do not agree with a decision on a benefit, a claim or an order (Art. 49 para. 1 ATSG);
2. you request one after the health insurer has decided informally (Art. 51 para. 2 ATSG);
3. the health insurer wants to enforce a claim, for example to recover benefits paid in excess (Art. 25 ATSG) or unpaid premiums after an objection in debt enforcement proceedings.

A written decision typically contains its designation as a written decision, the facts, the reasons, the decision itself (operative part) and information on how to appeal, with the deadline and address. If notification is defective, for example because the information on how to appeal is missing, this must not put you at a disadvantage (Art. 49 para. 3 ATSG).

Before a written decision against which an objection is possible, the health insurer does not have to hear you (Art. 42 ATSG). You get your right to be heard in the objection procedure. You lodge an objection against the written decision with the health insurer within 30 days. Against the response to the objection, you can turn to the cantonal insurance court.

Written decisions on money carry weight in debt enforcement. A creditor whose debt enforcement has been met with an objection must assert its claim in civil proceedings or in administrative proceedings (Art. 79 DEBA). The health insurer can do this with its own written decision that expressly sets aside the objection. Legally binding written decisions on payments of money are equivalent to enforceable judgments (Art. 54 para. 2 ATSG). If premiums remain unpaid, in cantons with a list of insured persons in arrears this can lead to a suspension of benefits.

Legal basis

Art. 49 ATSG is the central provision. Under paragraph 1, the insurer issues written decisions on benefits, claims and orders that are substantial or with which the person concerned does not agree. Paragraph 2 gives a right to a declaratory decision if you can show a legitimate interest. Paragraph 3 requires information on how to appeal and reasons if the written decision does not fully meet your requests. Paragraph 5 allows the health insurer to withdraw the suspensive effect of an objection, except in the case of repayment claims.

Art. 51 ATSG governs the informal procedure and your right to request a written decision. Art. 80 para. 1 KVG deviates from this: in health insurance, even substantial benefits are granted informally. Art. 52 ATSG governs the objection, Art. 53 ATSG the review and reconsideration of legally binding written decisions, Art. 54 ATSG enforceability.

For repayment claims, Art. 25 ATSG applies: benefits received without entitlement must be repaid. Anyone who received them in good faith does not have to repay them if this would cause serious hardship (para. 1). The health insurer’s claim expires three years after it became aware of it, but at the latest five years after the payment (para. 2).

Example: repayment claim by written decision

Marco is 52 years old. On 15.03.2021, his health insurer paid an invoice for CHF 1,200. On 02.02.2026, it finds that the service should not have been covered by basic health insurance and wants the money back. Marco does not agree. This is how the calculation looks with the statutory deadlines under Art. 25 para. 2 ATSG:

What this means for you

• Read the information on how to appeal. It tells you how much time you have and where to send the objection. The deadline starts on the day after delivery.
• Request a written decision if you want to object. As long as there is only an informal letter, you cannot contest anything.
• Act within 30 days. If you miss the deadline, the written decision becomes legally binding. Later, only a review based on new facts or evidence can help.
• Get advice. The Office of the health insurance ombudsperson mediates free of charge. However, it does not replace the objection.

The overview of Health insurers shows how the insurers are set up. You compare premiums for your municipality in the premium calculator.

Common mistakes

• Thinking every statement is a written decision. Without information on how to appeal, it is not a written decision. An objection would be premature.
• Leaving the written decision lying around. After 30 days, it is legally binding. For monetary claims, the health insurer can then enforce it as it would a judgment.
• Confusing written decisions with supplementary insurance. Rejections from supplementary insurance are not written decisions; the contract, the ICA and civil procedure apply there.
• Not checking the deadlines for a repayment claim. Three years from awareness, no more than five years from payment: a late repayment claim has expired.