Glasses, fitness, complementary medicine: which supplementary insurance pays for what?

Comparing supplementary insurance: first know what basic health insurance pays

If you compare supplementary insurance, you are usually comparing products that only fill gaps. Which gaps exist is determined by basic health insurance: it only pays for benefits provided for by the Federal Health Insurance Act (KVG), and no others (Art. 34 para. 1 KVG). Everything beyond that is covered by voluntary supplementary insurance under the Insurance Contract Act (ICA), whose benefits each insurer sets itself.

Most of these benefits are included in supplementary outpatient insurance. Product names are not standardised, and many insurers bundle several modules. That is why you compare conditions, not names.

Step by step: how to compare supplementary insurance

1. Write down your needs. Which benefits have you paid for yourself in the last two or three years? Glasses, courses, therapies outside basic health insurance, medicines not covered by the insurer. Your insurer’s statements of benefits help.
2. Subtract basic health insurance. For each benefit, check whether basic health insurance already pays, for example for children’s glasses or acupuncture by a doctor. Supplementary insurance only pays after that.
3. Lay the general terms and conditions side by side. For each benefit, five values count: percentage, maximum amount, period (per year or every three years), conditions (prescription, recognised provider) and maximum amounts shared with other benefits.
4. Ask for the premium for your age. Supplementary premiums depend on the product, age and often place of residence. A quote shows you the premium for your situation.
5. Clarify the acceptance conditions. The insurer may ask health questions and reject you (Art. 4 ICA). Ask about waiting periods and the term.
6. First the acceptance, then the cancellation. If you already have supplementary insurance, only cancel it once the new contract has been confirmed in writing.

We are building a comparison of supplementary insurance with the benefits of the tariffs side by side under Comparing supplementary insurance.

Glasses: basic health insurance for children, supplementary insurance for adults

In basic health insurance, glasses and contact lenses are aids and appliances. What the insurer pays is set out in the FOPH’s Aids and Appliances List (MiGeL); the insurer pays the costs up to the maximum reimbursement amount set there, and you bear the rest (Art. 24 of the Health Care Benefits Ordinance, KLV). For children and adolescents up to the age of 18, this is at most CHF 180.67 per year, with a prescription from an ophthalmologist. For adults, basic health insurance only pays in special cases, for example if eyesight changes because of an illness, a medicine or an operation. As with any bill, the contribution is subject to the deductible and retention fee.

For healthy adults with ordinary refractive errors, only supplementary insurance comes in. Look out for these points with the contribution towards spectacle lenses and contact lenses:

• Maximum amount and percentage: does the insurer pay a fixed amount or a share of the bill?
• Period: per calendar year, every two or every three years?
• Scope: only lenses, or also frames, contact lenses, prescription sunglasses?
• Condition: is a measurement by the optician sufficient, or is a prescription from an ophthalmologist required?
• Laser eye surgery: does the insurer count laser surgery towards the contribution for glasses?

The benefits page Does health insurance pay for glasses? explains all the details on basic health insurance.

Fitness: never from basic health insurance

Basic health insurance may not cover any costs other than the benefits under Art. 25–33 KVG (Art. 34 para. 1 KVG). A gym membership is not one of them. A fitness contribution is therefore only paid by supplementary insurance, usually from an outpatient or prevention module.

Medical training therapy must be distinguished from this. It is part of physiotherapy on medical referral, limited in time, and paid for by basic health insurance. Free training afterwards is a matter for supplementary insurance or for you.

When comparing, what counts is the percentage of the membership costs, the annual maximum, the list or quality label of recognised providers and whether fitness shares a maximum amount with other benefits such as courses or check-ups. Details are on the benefits page Does health insurance pay for a gym membership?.

Complementary medicine: who treats you decides

With complementary medicine, what counts is who provides the treatment. Basic health insurance pays for five methods if a doctor with a specialist title and the appropriate certificate of proficiency provides the treatment (Art. 4b KLV):

Method	Doctor’s proficiency programme
Acupuncture	Acupuncture – Chinese pharmacotherapy – TCM (ASA)
TCM pharmacotherapy	Acupuncture – Chinese pharmacotherapy – TCM (ASA)
Anthroposophic medicine	anthroposophically extended medicine (VAOAS)
Classical homeopathy	Homeopathy (SVHA)
Phytotherapy	Phytotherapy (SMGP)

If therapists without a medical degree provide the treatment, for example naturopaths, TCM therapists or osteopaths, only supplementary insurance pays. Which methods it recognises, what share per session applies and whether the therapist must be entered in a register is set by each insurer in its terms and conditions. Before the first session, ask the insurer whether the method and the therapist are recognised. More on this on the benefits page Does health insurance pay for complementary medicine?.

Other outpatient benefits compared

• Ambulance transport and rescue: Basic health insurance pays 50 % of transport costs, at most CHF 500 per calendar year, and 50 % of rescue costs in Switzerland, at most CHF 5,000 per calendar year (Art. 26 and 27 KLV). Whether supplementary insurance covers the rest is set out in the GTC.
• Medicines not on the List of Pharmaceutical Specialties: In principle, basic health insurance pays for medicines on the FOPH’s List of Pharmaceutical Specialties (Art. 52 para. 1 let. b KVG). Some supplementary products contribute to other medicines.
• Treatment abroad: Basic health insurance pays for emergency treatment during a temporary stay abroad, at most up to twice the amount that would be reimbursed in Switzerland (Art. 36 para. 2 and 4 KVV); international benefits assistance, for example in the EU, remains reserved. Supplementary products regulate cover abroad beyond this in different ways.
• Hospital: The semi-private or private ward is a separate module, supplementary hospital insurance. The article No contract between insurer and hospital explains how it relates to contracts between insurers and hospitals.

Example calculation: is the outpatient module worth it?

Example with fictitious people. Nora, 35, wears glasses, trains at a gym and goes to a shiatsu therapist without a medical degree because of muscle tension. Basic health insurance pays for none of these benefits. She is considering supplementary outpatient insurance with these conditions; all values are an assumed sample contract, not information from a specific insurer:

Benefit	Condition in the sample contract	Nora’s costs	Supplementary insurance contribution
Glasses	90 %, at most CHF 300 every 3 calendar years	CHF 600 every 3 years	CHF 300 every 3 years, i.e. CHF 100 per year
Gym membership	50 %, at most CHF 200 per year	CHF 800 per year	CHF 200 per year
Shiatsu, registered therapist	75 %, at most CHF 1,000 per year	8 sessions at CHF 120 = CHF 960	CHF 720 per year
Total			CHF 1,020 per year

The calculation only shows how to compare: realistic use against the annual premium, benefit by benefit. You decide whether a product suits you with your own figures and the insurers’ GTC. What counts are the GTC and the information from the insurer.

Special cases

Children. For children’s glasses, basic health insurance pays first, up to CHF 180.67 per year, and supplementary insurance possibly pays the rest. Submit the bill with the prescription so that both pots are checked.

Basic and supplementary insurance with different insurers. This is allowed. When you change basic health insurance, your previous insurer may not force you to cancel the supplementary insurance, nor cancel it for that reason alone (Art. 7 para. 7 and 8 KVG). You compare basic health insurance independently in the premium calculator, and Switching insurer describes the switch.

Pre-existing conditions. Because the insurer may ask health questions, a new product may contain a reservation. The insurer may not cancel an existing contract with ordinary notice (Art. 35a para. 4 ICA); a switch should therefore be considered carefully.

Revocation. If you have submitted an application and changed your mind, you can revoke it within 14 days (Art. 2a ICA).

Common mistakes

• Comparing by product name. “Outpatient Plus” means something different at every insurer. Compare percentage, maximum amount, period and conditions.
• Insuring benefits twice. Basic health insurance already pays for acupuncture by a doctor or for children’s glasses; supplementary insurance only helps with the rest there.
• Overlooking shared maximum amounts. If several benefits share one pot, it is used up more quickly.
• Not checking recognition. If the therapist or the gym is not recognised, the insurer pays nothing.
• Cancelling your old supplementary insurance too early. First the new insurer’s written acceptance, then the cancellation.

The article Premium increase in supplementary insurance explains how to react to a higher supplementary premium. You will find all topics relating to supplementary insurance in the Supplementary insurance section, and an overview of the insurers under Health insurers.