Reimbursement claim form: how to get your money back from your health insurer

When you receive a reimbursement claim form

Whether you need to claim money back from your health insurer depends on who pays the bill. The Federal Health Insurance Act provides for two routes. Under tiers garant, the bill goes to you: you pay the practice and claim back the health insurer’s share. Under tiers payant, the bill goes directly to the health insurer, and you receive a copy so you can check it. Unless the health insurer and the service provider have agreed otherwise, tiers garant applies (Art. 42 para. 1 KVG).

So the reimbursement claim form only exists under tiers garant. It is the copy of the bill intended for the health insurer, often a separate sheet or a copy marked for the health insurer. If the bill arrives electronically, it is the PDF that you upload to the health insurer’s app or customer portal.

Be careful with the terms: some health insurers also call their own claim against you a “reimbursement claim”, meaning the bill for the deductible and retention fee after they have paid under tiers payant. This article is about the opposite route: you have paid, and the health insurer owes you money.

Step by step: submitting a reimbursement claim form

1. Check the bill. Are your name, the treatment dates and the services correct? The bill must be detailed and understandable (Art. 42 para. 3 KVG) and must include, among other things, the calendar of treatments and the services provided at the level of detail of the tariff (Art. 59 para. 1 KVV). How to find errors is explained in the article Bill too high.
2. Pay the bill. You owe the practice the full amount within its payment deadline, even if the health insurer has not yet reimbursed you.
3. Submit the claim. Via the app, in the customer portal or by post. No form is required (Art. 42 para. 6 KVG). If you send it by post, write your insurance number on it and keep a copy.
4. Submit small bills too. Bills below your deductible do not bring you any money straight away, but they count towards the deductible.
5. Check the statement of benefits. After checking the claim, the health insurer sends you a statement of benefits. It shows how much was counted towards the deductible and retention fee and what the health insurer transfers.
6. Check the payment. If neither money nor a statement arrives after a few weeks, contact your health insurer and give the invoice number and the date you submitted the claim.

Service providers must issue two separate bills, one for benefits of basic health insurance and one for other services (Art. 59 para. 2 KVV). If you receive two claim forms, one often belongs to a supplementary insurance or is a service you pay yourself, such as a medical certificate for your employer. Submit both if you have a suitable supplementary insurance.

The legal rules on reimbursement

Entitlement: Under tiers garant, you are entitled to reimbursement from the health insurer (Art. 42 para. 1 KVG). You may assign this entitlement to the service provider; the health insurer then pays its share directly to the practice, and the deductible and retention fee remain with you.

Bill: The service provider must give you all the information you need to check the calculation and the cost-effectiveness of the service (Art. 42 para. 3 KVG). Since 01.07.2026, providers transmit bills electronically; at your request, you receive them on paper free of charge (Art. 42 para. 3ter KVG).

Allocation: The health insurer allocates each service to the date of treatment (Art. 24 para. 2 KVG). For the deductible and retention fee, the date of treatment counts (Art. 103 para. 3 KVV). A treatment in December 2026 belongs to the 2026 deductible, even if the bill only arrives in January 2027.

Deadline: The entitlement to outstanding benefits expires five years after the end of the month for which the benefit was due (Art. 24 para. 1 ATSG). There is no statutory deadline by which the health insurer must pay. It only owes default interest 24 months after the entitlement arose, at the earliest 12 months after you submitted the claim, and only if you cooperated in the investigation (Art. 26 para. 2 ATSG).

Paid too much: If you paid remuneration under tiers garant that was not owed, you yourself are entitled to claim it back; the health insurer can do this for you (Art. 56 para. 2 let. a KVG).

Dispute: If the health insurer does not pay, or pays less than you expect, you can ask for a written decision (Art. 49 para. 1 and Art. 51 para. 2 ATSG). You can file an objection to it; the procedure is described in the article Benefit rejected.

What the health insurer deducts: statutory amounts

The health insurer never reimburses the full amount of the bill as long as you have not used up your co-payment for the calendar year. The order is fixed: first the deductible, then a 10 % retention fee up to the annual maximum, after which the health insurer pays the whole bill.

Item	Adults from 26 and young adults	Children up to 18
Deductible per calendar year	CHF 300 (standard), optional CHF 500, 1,000, 1,500, 2,000, 2,500	CHF 0, optional CHF 100 to CHF 600
Retention fee	10 % of the costs above the deductible	10 % of the costs above the deductible
Annual maximum retention fee	CHF 700	CHF 350
Contribution to the hospital stay	CHF 15 per day	no contribution

Young adults in education also do not pay a hospital contribution (Art. 104 para. 2 KVV). The amount of your deductible is shown on your insurance policy. Which deductible would be cheaper for your costs, you can work out with the premiums of your municipality in the deductible calculator.

Sample calculation: four claims in one year

Example with fictitious people. Jonas, 45, is insured under the standard model and has a deductible of CHF 1,500. His GP practice and his physiotherapy practice bill under tiers garant. The amounts of the bills are assumed; the deductible and retention fee follow the law.

Jonas does not reach the annual maximum retention fee of CHF 700 this year. That would only happen with costs of CHF 8,500: a CHF 1,500 deductible plus CHF 7,000 on which the 10 % retention fee is charged.

Special cases

Changing health insurer during the year or at New Year

Claims always belong to the health insurer you were insured with on the date of treatment. If you switched on 01.01., you submit a bill for a treatment in November to your old health insurer, even if you only receive it in February. If you switch during the year, for example in the standard model with the standard deductible on 1 July, the new health insurer counts the deductible and retention fee you have already paid; if it lacks the information, you must provide proof (Art. 103 para. 4 KVV). So keep the statements of benefits from your old health insurer. The procedure for switching is described under Switching health insurer.

Supplementary insurance

For benefits from supplementary insurance, the rules of the KVG do not apply; your contract and the Insurance Contract Act do. Claims there become time-barred five years after the event giving rise to the obligation to pay (Art. 46 para. 1 ICA); shorter periods in the contract terms are invalid (Art. 46 para. 2 ICA). Whether and how much supplementary insurance pays, for example towards glasses or complementary medicine, is set out in the general terms and conditions. What counts are the general terms and conditions and the information from your health insurer.

Accident

If you are compulsorily insured against accidents through your employer, a bill after an accident belongs to the accident insurance, not to the health insurer. Report the accident to your employer and send the claim to the accident insurer.

The health insurer stops paying altogether

If a health insurer gets into financial difficulties, the question arises of who takes over outstanding reimbursements. How the law deals with this case is explained in the article Health insurer in bankruptcy. Key figures on the reserves and finances of each health insurer are shown in the health insurer profiles.

If nothing or too little comes back

The most common cause is the deductible: as long as it has not been reached, the health insurer pays nothing out. On the statement of benefits, check the status of your deductible first. If that is not the reason, there are three other typical causes:

• The service is not a compulsory benefit. Basic health insurance only pays for services that are provided for in the law and ordinances and that are effective, appropriate and cost-effective (Art. 32 and 34 KVG). A massage without a doctor’s prescription or a medical certificate for your employer are not among them.
• The bill is incomplete. If information required under Art. 59 KVV is missing, the health insurer asks the practice. That delays payment.
• The health insurer needs medical information. It can request additional details, and you can ask that these go only to the medical adviser (Art. 42 para. 4 and 5 KVG).

Ask for a written explanation. If you disagree, you are entitled to a written decision, against which you can file an objection within 30 days. The Office of the health insurance ombudsperson mediates free of charge as long as no written decision has been issued.

Common mistakes

• Keeping claims below the deductible. Then the amount is missing from your deductible, and later bills fill it up first. In the example, this costs Jonas CHF 162.
• Not paying the practice because the health insurer is still checking. Under tiers garant, you are the debtor. Reminder fees and debt enforcement hit you, not the health insurer.
• Submitting the copy of the invoice from tiers payant. The health insurer already has this bill. Submitting it twice only triggers queries.
• Sending the claim to your new health insurer. What counts is the health insurer on the date of treatment.
• Waiting for years. The five-year deadline is long, but old errors are hard to clarify, and the deductible for the year concerned was settled long ago.

You will find more basics, from the deductible to billing, in the section Understanding basic insurance. If you have similar costs every year, it is worth looking at your deductible and premium: the premium calculator shows all offers in your municipality with the FOPH premiums. You can save the results of our tools in your account.