Congenital disorders: when disability insurance pays instead of health insurance

Congenital disorders: two insurances, one clear order

A congenital disorder is an illness that exists at the time of completed birth (Art. 3 para. 2 of the Federal Act on the General Part of Social Insurance Law, ATSG). When it is detected does not matter: even a heart defect that only becomes apparent at kindergarten age can be a congenital disorder. Two insurances may pay for the treatment, and the law sets out the order:

1. Disability insurance (IV) pays first if the disorder is on the list of the FDHA Ordinance on Congenital Disorders (GgV-EDI) and meets the criteria of Art. 13 of the Federal Act on Disability Insurance (IVG). This applies until the child’s 20th birthday.
2. Basic health insurance pays for everything that disability insurance does not cover, “the same benefits as in the case of illness” (Art. 27 of the Federal Health Insurance Act, KVG). This applies to disorders that are not on the list, to treatments that disability insurance does not cover and to everything after the 20th birthday.

If disability insurance pays, there is no co-payment to the health insurer: the deductible and retention fee are part of health insurance (Art. 64 KVG), not of disability insurance.

Which congenital disorders disability insurance covers

Disability insurance does not pay for every congenital condition. Under Art. 13 para. 2 IVG, it must be diagnosed by a specialist, impair health, reach a certain degree of severity, require long-term or complex treatment and be treatable with medical measures; the last condition does not apply to trisomy 21 (Art. 13 para. 3 IVG). The Federal Department of Home Affairs (FDHA) determines which disorders qualify in the GgV-EDI list, which has applied since 01.01.2022 (Art. 3bis of the Disability Insurance Ordinance, IVV).

The list is organised by organ system, from the skin through the skeleton, heart and nervous system to metabolism. Examples from the annex:

Several numbers contain thresholds, such as measured values or the need for surgery. Whether your child meets them is decided by the disability insurance office after registration, not by the doctor and not by the health insurer.

What disability insurance pays

If disability insurance recognises a congenital disorder, it pays for the medical measures to treat it (Art. 14 para. 1 IVG):

• outpatient and inpatient treatment by doctors, chiropractors and specialists on a doctor’s order, for example physiotherapy or occupational therapy;
• medical nursing care, including outpatient care at home;
• prescribed analyses, medicines and aids and appliances;
• medical rehabilitation;
• the hospital stay on the general ward.

Disability insurance does not cover speech therapy (Art. 14 para. 3 IVG). If the child needs constant help in everyday life because of the disorder, a helplessness allowance may also be possible, and in the case of intensive care of at least 4 hours a day an intensive care supplement (Art. 42bis and 42ter IVG). For children under one year, the entitlement to a helplessness allowance arises as soon as the helplessness is expected to last more than 12 months (Art. 42bis para. 3 IVG).

Step by step: registering with disability insurance

1. Insure your child with a health insurer. You still need basic health insurance, no later than 3 months after the birth; it then applies retroactively from birth (Art. 3 para. 1 and Art. 5 para. 1 KVG). It pays for everything that disability insurance does not cover.
2. Clarify the diagnosis and the number. Ask the treating specialist whether she suspects a congenital disorder on the GgV-EDI list and which number might apply.
3. Submit the registration to the disability insurance office. The disability insurance office of your canton of residence is responsible; you will find the addresses at the Information Center OASI/DI.
4. Do not wait. If you register the entitlement more than 12 months after it arose, disability insurance only pays for the 12 months before registration (Art. 48 para. 1 IVG). It pays for longer only if you could not have known about the entitlement and register within 12 months of finding out (Art. 48 para. 2 IVG).
5. Inform the health insurer. As long as responsibility is disputed, you can ask the health insurer to pay in advance (Art. 70 ATSG). For some benefits, it requires a cost approval.
6. Check the decision. Disability insurance notifies you of its decision in writing. You plan benefits after the 20th birthday with the health insurer in good time.

Children’s premium and deductible with a congenital disorder

Basic health insurance remains important for your child, even if disability insurance pays for the treatment of the disorder. All other treatment goes through it: infections, accidents, check-ups that have nothing to do with the disorder. The children’s premium does not depend on this; every insurer must accept your child without health questions, even with a known disorder.

When choosing the child’s deductible, only the costs incurred with the health insurer count. Disability insurance benefits do not count towards the deductible.

Example with fictitious people. Emil is 4 years old and lives in Lausanne. Disability insurance pays for the therapies for his recognised congenital disorder. With the health insurer, doctor’s visits and medicines cost an additional CHF 500 per year (assumed). Premiums 2026, municipality of Lausanne (region 1), children, with accident cover, median; source FOPH: CHF 165.20 per month with a CHF 0 deductible, CHF 132.80 with a CHF 600 deductible.

The calculation is an example, not a recommendation. Recalculate with your child’s costs and the premiums in your municipality.

Special cases

Supplementary insurance

There is no obligation to accept applicants in supplementary insurance. Before concluding the contract, the insurer may ask health questions (Art. 4 of the Insurance Contract Act, ICA) and exclude a known congenital disorder with a reservation or reject the application. Some insurers accept children registered before birth without a health assessment; there is no statutory rule on this, and what counts are the general terms and conditions. What this means for planning is explained in the articles Insuring your baby and Supplementary insurance for your child.

Teeth and jaw

For certain congenital disorders affecting the teeth, basic health insurance pays for dental treatment if it is needed after the 20th birthday or if disability insurance was not responsible before (Art. 19a KLV). Which jaw and dental disorders disability insurance covers is shown in the article Dental insurance for children.

Children with foreign nationality

For children without a Swiss passport, additional insurance conditions apply, for example regarding the contribution period or the parents’ residence in Switzerland (Art. 9 para. 3 IVG). Clarify them with the disability insurance office before assuming that the health insurer has to pay for everything.

Transition at 20

The entitlement to medical measures from disability insurance ends at the end of the month in which your child turns 20 (Art. 3ter para. 2 IVV). From then on, basic health insurance pays for the treatment as for an illness (Art. 27 KVG), with the deductible and retention fee for young adults. Plan the deductible and model for the year of transition accordingly.

Common mistakes

• Postponing registration with disability insurance. As a rule, disability insurance does not pay more than 12 months retroactively.
• Assuming the diagnosis is enough. Without registration with the disability insurance office, disability insurance pays nothing, even for a disorder on the list.
• Neglecting basic health insurance. It pays for everything that is not part of the recognised disorder and, from the 20th birthday, for the whole treatment.
• Not checking statements. If the health insurer charges a disability insurance benefit, you pay an unnecessary deductible and retention fee.
• Clarifying supplementary insurance too late. After the diagnosis, the insurer may exclude the disorder.

You compare the children’s premiums of all insurers in your municipality in the premium calculator; key figures for the insurers are in the health insurer profiles. How to reduce children’s premiums further is shown in the article Saving on children’s premiums, and an overview of all points for parents in the Checklist for families. All topics are in the Family and children section.