No contract between hospital and health insurer: what it means for you

No contract: two insurances, two consequences

Hospitals, physicians and health insurers regularly negotiate prices. If they cannot agree, a situation without a contract arises. What this means for you depends on which insurance is affected.

In basic health insurance, a situation without a contract is mainly a problem between the insurer and the service provider; the law protects you. In supplementary insurance, it can cost you money, especially for planned procedures in the semi-private or private ward. That is why this article is in the topic Supplementary insurance.

Basic health insurance: tariff agreement, setting by the canton, tariff protection

In basic health insurance, hospitals and physicians bill according to a tariff agreement. The parties are individual service providers or their associations on one side and insurers or their associations on the other. The agreement only applies once the cantonal government or, for the whole of Switzerland, the Federal Council has approved it (Art. 46 para. 4 of the Federal Health Insurance Act, KVG). It can be terminated with at least 6 months’ notice (Art. 46 para. 5 KVG).

If no agreement is reached, the system does not come to a standstill:

• Setting the tariff: After hearing the parties involved, the cantonal government sets the tariff (Art. 47 para. 1 KVG).
• Extension: If the parties cannot agree on a renewal, the cantonal government can extend the existing agreement by one year; if there is still no agreement after that, it sets the tariff (Art. 47 para. 3 KVG).
• Tariff protection: For services under the KVG, service providers must comply with the tariffs set by agreement or by the authorities and may not charge any further remuneration (Art. 44 para. 1 KVG).
• Opting out: If a service provider no longer wants to provide any services under the KVG at all, it must report this to the office designated by the canton and inform you beforehand; it then has no entitlement to remuneration under the KVG (Art. 44 para. 2 KVG). If care is not guaranteed as a result, the cantonal government ensures it (Art. 45 KVG).

For you, this means: if a hospital on the Hospital List treats you in the general ward, the canton and the insurer pay even without an agreement, according to the tariff that has been set. As always, you pay the deductible, the retention fee and, as an adult, in principle the hospital contribution of CHF 15 a day (Art. 104 of the Health Insurance Ordinance, KVV).

Listed hospital, contract hospital, outside your canton

Another case is often confused with a situation without a contract: a hospital that is not on any Hospital List at all. The free choice of hospital in basic health insurance applies among the listed hospitals of your canton of residence and the canton where the hospital is located (Art. 41 para. 1bis KVG). Insurers may conclude agreements with hospitals that are not on a list, but they pay at most their own share there; the canton pays nothing (Art. 49a para. 4 KVG). In such a contract hospital, a large part of the bill remains with you unless you have suitable supplementary insurance. In a listed hospital, the canton pays at least 55 % (Art. 49a para. 2ter KVG).

If you choose a listed hospital outside your canton of residence without a medical reason, the insurer and the canton pay at most the tariff that applies in a listed hospital in your canton of residence (Art. 41 para. 1bis KVG). Only supplementary insurance that provides for it covers any difference.

Supplementary insurance: cover remains, a difference is possible

In supplementary hospital insurance, for example for the semi-private ward or private ward, insurers negotiate with hospitals and physicians on the prices of additional services: the room, free choice of physician, additional fees. These agreements are governed by private law; there is no setting by the authorities as in basic health insurance. If the parties cannot agree, there is no contract for these additional services.

FINMA supervises supplementary insurers. Since 2020, it has required insurers to pay only for genuine additional services and invoices to be transparent. It explicitly states that situations without a contract can arise when agreements are renegotiated (press release of 17.12.2020). In its press release of 16.01.2025, it describes a temporary or, in individual cases, permanent situation without a contract as a possible alternative in the interest of insured persons. For you, it states two points:

• Your insurance cover exists regardless of any contract between the supplementary insurer and the hospital.
• In any case, you are entitled to the benefits that the general terms and conditions of your supplementary insurance promise you.

However, this does not mean that you never pay anything. Without a contract, the hospital or physician can invoice you directly for the additional services, at their own prices. Your insurer pays what the general terms and conditions provide for. If the invoice is higher, the difference remains with you. How your insurer deals with hospitals without a contract, for example with lists of recognised hospitals or maximum amounts, is set out in your general terms and conditions. The general terms and conditions and the information from your insurer are decisive.

Step by step: before a planned hospital admission

1. Ask early. Ask your insurer in writing whether it has a contract with the hospital and the treating physicians for your ward.
2. Request cost approval. Before admission, get written confirmation of which costs your supplementary insurance will cover. State the hospital, the procedure, the ward and the expected length of stay.
3. Get a cost estimate from the hospital. Ask the hospital which additional services it will invoice you for, including physicians’ fees.
4. Calculate the difference. Compare the cost estimate with the cost approval. The gap is your risk.
5. Consider alternatives. Another hospital with a contract, treatment in the general ward of the listed hospital or a later date if the parties are likely to agree soon.
6. Keep your documents. Keep the cost approval, the cost estimate and the invoices. In a dispute, the Office of the health insurance ombudsperson mediates free of charge.

Example: planned operation in a hospital without a contract

Example with fictitious people. Thomas, 56, has semi-private supplementary hospital insurance. For a planned operation, he wants to go to a listed hospital with which his insurer has no contract for the semi-private ward. The amounts are assumed, as is the rule in his general terms and conditions: for hospitals without a contract, the insurer pays for additional services at most up to the amount it pays comparable contract hospitals.

Without cost approval and a cost estimate, Thomas would only have seen the difference when the invoice arrived.

Special cases

Emergency. In an emergency, you are treated at the nearest suitable hospital. Basic health insurance also pays in a hospital that is not on the list of your canton of residence if there are medical reasons; an emergency counts as one (Art. 41 paras 3 and 3bis KVG). How supplementary insurance treats emergencies in hospitals without a contract is set out in the general terms and conditions.

Outpatient physicians. There are also tariff agreements for outpatient treatment. The same rules apply in basic health insurance: setting by the canton and tariff protection. If a physician has opted out, they must inform you beforehand (Art. 44 para. 2 KVG).

Switching insurer because of missing contracts. You can switch basic health insurance on the dates set by the KVG without losing your supplementary insurance; your previous insurer may not cancel it solely because of the switch (Art. 7 para. 8 KVG). The procedure is shown under Switching health insurer, and you compare premiums in the premium calculator. You can cancel the supplementary insurance itself with ordinary notice at the end of the third or any later contract year (Art. 35a of the Insurance Contract Act, ICA). A new insurer may ask health questions and turn you down; so only cancel once you have been accepted.

Contract taken out through an intermediary. If you have taken out hospital insurance that you did not really want, the article Unwanted supplementary insurance explains the ways out.

Common mistakes

• Going into hospital without cost approval. For a planned procedure, you will otherwise only see the gap on the invoice.
• Forgetting physicians’ fees. Not only the hospital but also individual physicians may have no contract with your insurer.
• Mixing up basic and supplementary insurance. Tariff protection applies to services under the KVG. Additional amounts can only concern the additional services of supplementary insurance.
• Cancelling supplementary insurance straight away. A situation without a contract can be temporary, and a new contract requires health questions.
• Confusing listed hospitals and contract hospitals. In a contract hospital, the canton pays nothing; in a listed hospital, it pays at least 55 %.

Which supplementary products offer which benefits is shown in the article Which supplementary insurance pays for what?. You can find all topics on supplementary hospital and outpatient insurance in the topic Supplementary insurance, and details of the individual insurers under Health insurers.