Claim refused: your rights, objection and ombudsperson

Basic or supplementary insurance: two different routes

Before you challenge a refusal, check which insurance refused. Basic health insurance is a social insurance. It is governed by the Federal Act on the General Part of Social Insurance Law (ATSG), with a fixed procedure: the insurer decides by means of a written decision, you can lodge an objection, and after that a court decides. Supplementary insurance is a private contract under the Insurance Contract Act (ICA). There, there is no written decision and no objection; a dispute is a contractual dispute.

Both types of insurance are often listed one below the other on the statement of benefits. Check which line the refusal is on. If the insurer refuses a benefit under basic health insurance but pays it from supplementary insurance, this is not a dispute but a different allocation.

Step by step: how to challenge a refusal in basic health insurance

1. Ask for the reasons. Ask in writing why the insurer will not pay, giving the invoice number and the date of treatment. The insurer must inform and advise you about your rights and obligations (Art. 27 ATSG).
2. Add documents. Many refusals are due to missing information. Ask your physician for a report explaining why the treatment is necessary. She can only send medical information to the insurer’s medical adviser; if you ask her to, she must do so (Art. 42 para. 5 KVG).
3. Involve the ombudsperson. As long as the insurer has not yet issued a written decision, the Office of the health insurance ombudsperson mediates free of charge.
4. Ask for a written decision. If the insurer maintains its refusal, ask in writing for a written decision that can be challenged (Art. 51 para. 2 ATSG). The insurer may not make this dependent on an internal series of appeal stages (Art. 80 para. 3 KVG).
5. Lodge an objection. Within 30 days of notification of the written decision, with the insurer that issued it (Art. 52 para. 1 ATSG). The objection needs a request and a statement of reasons (Art. 10 para. 1 ATSV).
6. Appeal to the insurance court. If the insurer rejects the objection, you can appeal within 30 days to the insurance court of your canton of residence (Art. 58 and 60 ATSG).
7. Federal Supreme Court. An appeal to the Federal Supreme Court is possible against the judgment of the cantonal court (Art. 62 ATSG).

The first three steps resolve many cases. You only need the written decision if you want to take formal action; from then on, fixed deadlines apply.

Why insurers refuse benefits

Basic health insurance only pays for what the law provides. Services must be effective, appropriate and cost-effective (Art. 32 para. 1 KVG), and the insurer may not cover any costs other than the statutory ones (Art. 34 para. 1 KVG). Most refusals can be traced back to one of these reasons:

In a special type of insurance, the insurer only has to cover services provided or arranged by the chosen service providers (Art. 41 para. 4 KVG). Which rules apply in your model is set out in your insurer’s model conditions. With a suspension of benefits under Art. 64a para. 7 KVG, the insurer postpones covering the costs, except for emergency treatment; the suspension is lifted once the outstanding claims have been paid.

Which services need cost approval and how to apply for it is explained on the page Cost approval. If your dispute is not about the service but about the amount, the article Checking a TARDOC invoice helps.

The role of the medical adviser

On medical questions, the insurer does not decide alone. Medical advisers advise it and, in particular, review whether the requirements for the obligation to pay are met (Art. 57 para. 4 KVG). They are independent in their judgement; neither the insurer nor the service providers can give them instructions (Art. 57 para. 5 KVG). They only pass on to the benefits department what is necessary for the decision (Art. 57 para. 7 KVG).

For you, this means: a refusal on medical grounds is usually based on your physician’s report and the medical adviser’s assessment. If you want to dispute it, you usually need a new or more detailed medical report, not just your own reasoning. You have the right to inspect the data concerning you (Art. 47 para. 1 ATSG); ask your insurer for it before you write your objection.

The objection: form, content and deadlines

Form: You can submit the objection in writing or raise it orally in person at the insurer’s office; the insurer then records it in minutes, which you sign (Art. 10 para. 3 and 4 ATSV). A written objection is easier to prove: send it by registered mail and sign it.

Content: A request (“The written decision of 10.07.2026 is to be set aside and the costs of the treatment of … are to be covered”) and a statement of reasons. If something is missing, the insurer sets you a deadline to correct it (Art. 10 para. 5 ATSV). Enclose copies of the written decision, the invoice and medical reports.

Deadline: 30 days from notification (Art. 52 para. 1 ATSG). The deadline starts on the day after delivery (Art. 38 para. 1 ATSG). If it ends on a Saturday, Sunday or public holiday, it runs until the next working day (Art. 38 para. 3 ATSG). It is met if you hand the objection to Swiss Post on the last day at the latest (Art. 39 para. 1 ATSG). A statutory deadline cannot be extended (Art. 40 para. 1 ATSG).

Suspension of deadlines: The deadline is suspended from the seventh day before Easter to the seventh day after Easter, from 15 July up to and including 15 August, and from 18 December up to and including 2 January (Art. 38 para. 4 ATSG).

Costs: The objection procedure is free of charge; as a rule, there is no compensation for a lawyer (Art. 52 para. 3 ATSG).

Example: an objection in summer

Example with fictitious people. Mirjam, 52, lives in the canton of Lucerne. Her insurer refuses to extend a therapy. Mirjam asks for a written decision and receives it by registered mail on Friday, 10.07.2026.

Mirjam encloses with her objection a new report from her physician describing the course so far and the aim of the therapy. Whether the insurer then decides differently depends on the individual case; there is no guarantee.

Before the insurance court

If the insurer rejects the objection, you receive a reasoned response to the objection with information on legal remedies (Art. 52 para. 2 ATSG). You can appeal against it within 30 days (Art. 60 para. 1 ATSG). This also applies if the insurer does not issue a written decision or a response to the objection despite your request (Art. 56 para. 2 ATSG). Every canton has an insurance court as the sole cantonal instance (Art. 57 ATSG); the court of your canton of residence is responsible (Art. 58 para. 1 ATSG).

The procedure must be simple and quick. The appeal needs a brief statement of the facts, a request and a statement of reasons; if it is incomplete, the court sets you a deadline to correct it (Art. 61 let. a and b ATSG). The court establishes the facts itself and is not bound by the requests; it can also change the decision to your disadvantage, but must first give you the opportunity to withdraw the appeal (Art. 61 let. c and d ATSG). Under the KVG, court costs only arise if you litigate wilfully or frivolously (Art. 61 let. fbis ATSG). If you win, you are entitled to reimbursement of your costs (Art. 61 let. g ATSG).

Supplementary insurance: a contract, not a written decision

If your insurer refuses a benefit from supplementary insurance, your contract applies. The general insurance conditions and the information from your insurer are decisive, not the KVG. The insurer does not issue a written decision, and there is no objection. This is how to proceed:

1. Read the general insurance conditions. Check whether the service is insured, whether there are waiting periods, maximum amounts or reservations and whether prior approval was required.
2. Object in writing. Write to the insurer explaining why, in your view, the service is covered, and refer to the relevant clause of the general insurance conditions.
3. Involve the ombudsperson. The Office of the health insurance ombudsperson is also responsible for supplementary insurance and mediates free of charge.
4. Civil court. If the dispute continues, it goes before a civil court. Cantons can designate a single court for this (Art. 7 CPC); some choose their insurance court.

Claims under the insurance contract become time-barred five years after the event giving rise to the obligation to pay (Art. 46 para. 1 ICA). For a legal dispute, legal expenses insurance or independent legal advice may be useful.

And if you want to switch insurer?

A refused benefit is not a reason for cancellation that frees you from deadlines. In basic health insurance, you switch on the regular dates; your notice of cancellation must reach the insurer by 30 November (Art. 7 KVG). Your previous insurer remains responsible for the refused treatment, because it was your insurer on the date of treatment. The benefits of basic health insurance are the same at every insurer, so switching does not change whether a treatment is a compulsory benefit. It may still be worthwhile because of the premium, the model or the service. The premium calculator shows the premiums of all insurers for your municipality, and the page Switching health insurer shows the process and its deadlines.

Common mistakes

• Missing the deadline because the ombudsperson is looking into the case. The objection deadline keeps running. If there is a written decision, submit the objection yourself on time.
• Only complaining by phone. Without a written request, there is no proof and no written decision. Ask for the written decision in writing.
• An objection without a request and reasons. A sentence like “I do not agree” is not enough. Write what the insurer should pay and why.
• Confusing basic and supplementary insurance. There is no objection under the ATSG against a refusal from supplementary insurance.
• Relying on a decision given by phone. Have commitments to cover costs confirmed in writing, especially for expensive treatment.

How billing works before a refusal is explained in the article Reimbursement claim form. You can find all the basics of basic health insurance in the topic area Understanding basic insurance. Your insurer’s contact channels and key figures are in the health insurer profiles.