Does health insurance pay for braces?

What basic health insurance pays

Braces are orthodontic treatment and therefore a dental service. Art. 31 of the Federal Health Insurance Act (KVG) applies: basic health insurance only pays if the treatment is required by a severe, unavoidable disease of the masticatory system, by a severe general illness or by an accident. Standard orthodontics for crooked teeth, crowding or for aesthetic reasons meets none of these conditions.

Who pays depends on the cause, severity and age:

Disability insurance first: Disability insurance (IV) pays for medical measures for congenital disorders up to the age of 20 (Art. 13 para. 1 IVG). The disorder must be diagnosed by a specialist, impair health, reach a certain degree of severity and require long-term or complex treatment (Art. 13 para. 2 IVG). Which dental and jaw conditions qualify is listed in the annex to the FDHA Ordinance on Congenital Disorders (GgV-EDI), including cleft lip, jaw and palate (item 201), the congenital absence of several permanent teeth (item 206) and congenital jaw misalignments such as a retruded lower jaw, open bite, deep bite or a protruding lower jaw (items 208–210). For jaw misalignments, the list requires certain measurements from an X-ray measurement of the skull, and the diagnosis must be made by an orthodontic specialist whom disability insurance has recognised for this assessment. Entitlement ends at the end of the month in which the person turns 20 (Art. 3ter IVV).

Basic health insurance afterwards or in addition: Art. 19a of the Health Care Benefits Ordinance (KLV) lists the congenital disorders for which basic health insurance covers dental treatment if it is needed after the age of 20 or if the person was not previously insured with disability insurance. The list contains the same jaw misalignments with the same measurements (items 20–22). Regardless of age, basic health insurance pays for jaw misalignments that lead to sleep apnoea syndrome, severe swallowing disorders or severe craniofacial asymmetries; the condition must be of pathological significance, and only what this pathological significance makes necessary is paid for (Art. 17 KLV).

What supplementary insurance pays

For standard braces, there is only voluntary dental insurance, often as a module of supplementary outpatient insurance. It is governed by the Insurance Contract Act (ICA), which does not prescribe any benefits. The insurer sets out in its general terms and conditions:

• whether orthodontics is covered at all,
• what percentage it pays and up to what maximum amount, often with a separate limit for orthodontics per treatment or per year,
• up to what age orthodontics is insured,
• what waiting period applies after taking out the policy.

Timing is decisive: before you take out the policy, the insurer may ask health questions and request a dental report. You must answer the questions truthfully (Art. 4 ICA). If a misalignment has already been found or treatment is planned, it is usually excluded. Supplementary insurance to health insurance can only be cancelled with ordinary notice by the policyholder, usually the parents, not by the insurer (Art. 35a para. 4 ICA).

We are building a comparison of benefits for supplementary products under Supplementary insurance; the health insurer profiles show which insurer offers which products. What always counts are the general terms and conditions and the information from your insurer.

Conditions

• Registration with disability insurance: Disability insurance only pays if the child is registered with the disability insurance office of the canton of residence and disability insurance has issued a decision on entitlement. The orthodontist’s diagnosis alone is not enough. More on this in the article Congenital disorders: when disability insurance pays instead of the health insurer.
• Order of insurances: For medical treatment, disability insurance takes precedence over health insurance (Art. 64 para. 2 ATSG). If it is unclear who is responsible, the health insurer must pay in advance (Art. 70 ATSG); if disability insurance refuses, basic health insurance pays if there is a case under Art. 17 or 19a KLV (Art. 27 KVG).
• Cost estimate: Before treatment starts, the practice draws up a cost estimate. Submit it to disability insurance, basic health insurance or the dental insurer before treatment begins.
• Co-payment: If disability insurance pays, the health insurer’s deductible and retention fee do not apply. If basic health insurance pays, a child bears no standard deductible but a 10 % retention fee of up to CHF 350 per year (Art. 64 para. 4 KVG, Art. 103 KVV). If the parents have chosen an optional deductible, the bill first counts towards it. Adults bear the deductible and a retention fee of up to CHF 700.
• Dental insurance in good time: Supplementary insurance only pays if it was taken out before the diagnosis and any waiting period has expired.

Example calculation

Example with fictitious people, assumed treatment costs and a sample contract. Lia is 11. The orthodontist finds a misalignment of the teeth of no pathological significance and proposes fixed braces over two years; the cost estimate is an assumed CHF 6,000.00. There is no congenital disorder. Her parents took out dental insurance for Lia when she was 3, which in the sample contract pays 75 % of orthodontics, up to CHF 3,000 per treatment.

Without dental insurance, the parents pay the full CHF 6,000.00. Had they only taken out the insurance after the check-up at which the orthodontist found the misalignment, the insurer would usually have excluded the treatment.

Whether dental insurance pays off for a child depends on its premium over the years until treatment and on the limit for orthodontics. You can calculate your child’s basic health insurance premium in the child premium calculator, and the premiums for the whole family in the premium calculator.

How to proceed

1. Compare early: If you want to cover the cost of braces, take out dental insurance before a misalignment is found. The article Dental insurance for children shows what matters.
2. Have the findings clarified: Ask the orthodontist whether a misalignment of pathological significance or a congenital disorder under the GgV-EDI could be involved.
3. Disability insurance first: If a congenital disorder could be involved, register your child with the disability insurance office before treatment starts.
4. Submit the cost estimate: Send it to the responsible body and wait for the reply.
5. Collect the bills: Orthodontic treatment often lasts several years. Keep all bills and check when the dental insurance limit has been reached.

Common mistakes

• Taking out dental insurance only after the check-up. A misalignment that has been found is usually excluded from cover.
• Forgetting to register with disability insurance. Without registration, disability insurance does not pay, even if there is a congenital disorder.
• Assuming every severe misalignment is a congenital disorder. The GgV-EDI requires precisely defined measurements and the diagnosis of an orthodontic specialist recognised by disability insurance.
• Overlooking the 20th birthday. If disability insurance treatment continues beyond the end of the month in which the person turns 20, basic health insurance pays from then on, with deductible and retention fee.

The page Dentist explains which other dental treatments basic health insurance covers. The article Supplementary insurance for your child deals with other supplementary insurance for children, and you will find all benefits in the overview What does health insurance cover?.