What does health insurance cover? Benefits from A to Z

The basic rule: a benefits catalogue, not case-by-case decisions

Basic health insurance does not pay for everything that seems medically sensible, but for what the law provides. It covers the costs of services used to diagnose or treat an illness and its consequences (Art. 25 para. 1 KVG), as well as certain preventive measures and benefits for congenital disorders, accidents not covered by accident insurance, maternity and legal termination of pregnancy (Art. 26–31 KVG). The insurer may not cover any other costs in basic health insurance, not even as a goodwill gesture (Art. 34 para. 1 KVG).

Which service is covered in detail is set out in the benefits catalogue: in the KVG, in the Health Care Benefits Ordinance (KLV) and in the federal lists. The most important lists are the List of Pharmaceutical Specialties (SL) for medicines, the List of Analyses for laboratory tests and the Aids and Appliances List (MiGeL) for aids and appliances such as spectacle lenses, breast pumps or dressing material. In addition, every service must be effective, appropriate and cost-effective (effectiveness, appropriateness and cost-effectiveness criteria, Art. 32 para. 1 KVG).

The benefits are the same at every insurer. Whether glasses, physiotherapy or rehab: in basic health insurance there is no “more generous” insurer. Differences only arise in supplementary insurance, whose benefits are set by the contract.

This topic area is structured as follows: first the rules that apply to all benefits, then the 41 benefit pages organised by area, and finally what you can do if your insurer does not pay. Every benefit page follows the same template: what basic health insurance pays, what supplementary insurance typically adds, which conditions apply, and a sample calculation.

Under what conditions does health insurance pay?

A service being in the catalogue is not enough on its own. The insurer pays if four conditions are met:

1. Licensed service providers. The treatment is provided by a person or institution licensed for basic health insurance, such as physicians, chiropractors, hospitals on the Hospital List or physiotherapists working on a physician’s order (Art. 35 para. 2 KVG). Osteopaths are not among them. What “recognised” means for therapists in basic and supplementary insurance is explained in Therapists recognised by health insurers.
2. An order or prescription where required. The insurer only pays for physiotherapy, occupational therapy, speech therapy, nutritional advice, podiatry and psychological psychotherapy if a physician orders them, often with a maximum number of sessions per order. Medicines, analyses and aids and appliances require a prescription.
3. Cost approval where prescribed. For certain services, the insurer must agree in advance, for example for medicines used outside their authorisation, certain dental treatments or therapies beyond a session limit. When this applies and how quickly the insurer has to decide is set out in Cost approval: when your health insurer requires it.
4. The rules of your insurance model. In the standard model, you choose your physician and therapist freely (Art. 41 para. 1 KVG). In the GP, HMO or telemedicine model, the insurer pays for many services only if your first point of contact refers you (Art. 41 para. 4 KVG).

If another insurer is responsible, it pays first: after an accident with cover under the UVG, the accident insurance; for recognised congenital disorders until the age of 20 is reached, invalidity insurance (IV); for hearing aids, the IV or old-age insurance (AHV). Your health insurer only steps in where no other insurance pays.

What do you pay yourself? Deductible, retention fee, hospital contribution

Even if the insurer covers a service, you share the costs (Art. 64 KVG). Adults first pay the deductible they have chosen, from CHF 300 to CHF 2,500 (Art. 93 para. 1 KVV), then a 10 % retention fee, up to a maximum of CHF 700 a year (Art. 103 para. 1 and 2 KVV). Children have no deductible, and their retention fee is capped at CHF 350 (Art. 64 para. 4 KVG). In hospital, there is an additional contribution of CHF 15 per day; children, young adults in education and women in connection with maternity do not pay it (Art. 104 KVV).

There are two exceptions you need to know. Maternity benefits, from the 13th week of pregnancy until eight weeks after the birth, are exempt from the deductible and the retention fee (Art. 64 para. 7 KVG). And certain preventive services in cantonal programmes, such as mammography screening, are exempt from the deductible; the retention fee still applies (Art. 64 para. 6 KVG). No supplementary insurance may cover the co-payment (Art. 64 para. 8 KVG).

Example with assumed values.

Which deductible is cheaper for your expected costs is worked out by the deductible calculator using the premiums for your municipality.

Benefits from A to Z by area

Each entry gives the key point in one sentence. The details, the legal basis and a sample calculation are on the linked benefit page. For supplementary insurance, the same applies everywhere: the general insurance conditions and the information from your insurer are decisive.

Therapies ordered by a physician

• Physiotherapy: covered on a physician’s order from licensed physiotherapists, at most nine sessions per order; after 36 sessions, the medical adviser reviews the case (Art. 5 KLV).
• Lymphatic drainage: covered as lymphological physiotherapy, with the same rules as physiotherapy.
• Massage: only as part of physiotherapy ordered by a physician; massages from medical masseurs are paid for, at most, by supplementary insurance.
• Occupational therapy: covered on a physician’s order, for example for physical illnesses or for fall-risk assessment from 65, at most nine sessions per order.
• Speech therapy: covered on a physician’s order if the disorder has a neurological or phoniatric cause, at most twelve sessions per order.
• Psychotherapy: directly with psychiatrists, with psychological psychotherapists on a physician’s order, at most 15 sessions per order.
• Nutritional advice: covered on a physician’s order for certain illnesses such as obesity from a BMI of 30, at most 6 sessions per order.
• Podiatry: only for diabetes with a risk of diabetic foot syndrome, 4 or 6 sessions per calendar year.
• Chiropractic: covered, in the standard model without a referral, because chiropractors are service providers in their own right.
• Osteopathy: not covered, not even with a prescription; at most, supplementary outpatient insurance pays part of it.
• Recognised therapists: the difference between being licensed in basic health insurance and being recognised by your supplementary insurance.

Complementary medicine

• Complementary medicine: five methods are covered if a physician with a certificate of proficiency provides the treatment: acupuncture, anthroposophic medicine, TCM drug therapy, classical homeopathy and phytotherapy (Art. 4b KLV).
• Acupuncture: only with physicians holding the relevant certificate of proficiency; with non-medical therapists, at most through supplementary insurance.

Teeth and eyes

• Dentist: only in exceptional cases such as severe, unavoidable diseases of the masticatory system or severe general illnesses (Art. 31 KVG); not check-ups, caries or crowns.
• Dental hygiene: not covered; only dental insurance contributes to it.
• Braces: the usual braces are not covered; for recognised congenital disorders, the IV pays up to the age of 20, then basic health insurance.
• Glasses: only for children up to 18, at most CHF 180.67 per year, with an ophthalmologist’s prescription (Art. 24 KLV); adults only in special medical cases.
• Laser eye surgery: as a rule not covered; only in one narrowly defined special case with cost approval.

Pregnancy, birth and contraception

• Midwife: covered during pregnancy, birth and the postnatal period, without deductible or retention fee, with up to 10 home visits after the birth, up to 16 for the first child.
• Antenatal classes: CHF 150 towards a course or a counselling session with a midwife (Art. 14 KLV).
• Breastfeeding advice: three sessions, without deductible or retention fee (Art. 15 KLV).
• Breast pump: only with a physician’s prescription and a medical reason, from the MiGeL, rented or bought up to fixed maximum amounts.
• Termination of pregnancy: a legal termination is covered like treatment for an illness (Art. 30 KVG), with deductible and retention fee.
• Contraception: the pill, the IUD and other contraceptives are not covered.
• Sterilisation and vasectomy: only in narrow medical cases; otherwise you pay the costs yourself.

Screening and prevention

• Preventive check-ups: no general check-up; only the preventive services listed in the KLV are covered.
• Mammography: from 50, every two years in the early detection programme without deductible; at any age if there is an increased risk or suspicion.
• Colonoscopy: as a screening between 50 and 74 every 10 years, as well as after a positive stool test and in case of symptoms.
• Vaccinations: the vaccinations in Art. 12a KLV, if they are indicated for you under the FOPH reference document; not travel vaccinations.
• Second opinion: a medically justified second opinion is a normal consultation; in a cost-saving model only with a referral.

Medicines and cost approval

• Weight-loss injection: only under strict conditions, with cost approval, BMI thresholds and for a maximum of 3 years.
• Cost approval: when the insurer has to agree in advance and how to submit the request.

Care, rehabilitation and aids and appliances

• Spitex: fixed contributions per hour towards assessment, treatment care and basic care; not household help or assistance.
• Household help: not covered, not even after an operation or a birth; at most supplementary insurance or supplementary benefits.
• Rehabilitation: medical rehab ordered by a physician, outpatient or inpatient, inpatient in a clinic on the Hospital List.
• Spa treatment: CHF 10 per day towards spa treatment ordered by a physician, at most 21 days a year; not recuperative stays.
• Rollators and aids: only items in the MiGeL are covered; the IV lends out rollators.
• Hearing aid: the IV, AHV or accident insurance pays a flat rate first; basic health insurance only if none of them is responsible.
• Fitness: no gym membership; only prescribed medical training therapy with a physiotherapist is covered.

Transport and abroad

• Patient transport and rescue: 50 % towards medically necessary transport, up to CHF 500 a year, and 50 % towards rescues in Switzerland, up to CHF 5,000 a year (Art. 26 and 27 KLV).
• Treatment abroad: emergencies during a temporary stay, outside the EU, EFTA and UK at most twice the Swiss costs (Art. 36 KVV); not repatriation.

What does basic health insurance not pay for?

Anything that is not in the benefits catalogue, even if it seems medically sensible. The most common gaps from the benefit pages above: routine dental treatment and dental hygiene, glasses for adults, osteopathy, treatment by non-medical complementary therapists, gym memberships, household help, contraceptives, rollators and recuperative stays. In hospital, basic health insurance covers the general ward, not a two-bed or single room. It does not pay for repatriation from abroad, and it pays for rescues and transport only by half, up to a maximum amount.

For some of these gaps, there is supplementary insurance: supplementary outpatient insurance for glasses, complementary medicine or fitness, dental insurance, supplementary hospital insurance for the semi-private or private ward, and travel insurance for abroad. It is voluntary, the insurer may ask health questions and refuse you, and what it pays is set out solely in the contract. Which of these makes sense for you is explained in the topic area Supplementary insurance; we are building a structured comparison of supplementary products under Compare supplementary insurance.

What can you do if your health insurer refuses to pay?

First ask, then request a written decision. A refusal is often due to a missing prescription, an exceeded number of sessions or missing cost approval; this can be sorted out with the physician or therapist. If you do not agree with the decision, ask your insurer for a written decision (Art. 49 para. 1 ATSG). You can lodge an objection against it within 30 days (Art. 52 para. 1 ATSG); the objection procedure is free of charge (Art. 52 para. 3 ATSG).

The Office of the health insurance ombudsperson also mediates between you and your insurer free of charge. It does not make binding decisions, but it often clarifies quickly whether the insurer has billed correctly. In supplementary insurance, there is no written decision: the contract applies there, and disputes are decided by a court, not through an objection procedure with the insurer.

Where to start?

1. Look up the service: Find the matching benefit page above. The first paragraph of each page answers whether basic health insurance pays.
2. Check the conditions: Do you need a physician’s order, a prescription or cost approval? Clarify this before the treatment, not afterwards.
3. Mind your insurance model: If you are insured in a GP, HMO or telemedicine model, have your first point of contact refer you first.
4. Work out your own share: How much of your deductible you have already paid this year is shown on your insurer’s statement of benefits. You work out the rest with a 10 % retention fee up to CHF 700.
5. Review your premium and deductible: If you have high costs every year, it is worth looking at your deductible and model. The premiums for your municipality are shown in the premium calculator, the insurers’ key figures in the health insurer profiles.