Cost approval: when your health insurer requires it

What basic health insurance only pays with cost approval

Cost approval is your health insurer’s commitment to pay for a specific treatment before it takes place. In the ordinances, it is called “special approval by the insurer”. Most benefits of basic health insurance do not need one: a doctor’s visit, laboratory tests, a medicine on the List of Pharmaceutical Specialties within its authorised scope or an emergency in hospital are paid if they are effective, appropriate and cost-effective, the effectiveness, appropriateness and cost-effectiveness criteria (Art. 32 para. 1 KVG). Prior approval is only compulsory where the KVV or KLV expressly requires it.

Approval for medicines in individual cases is only granted under strict conditions: the medicine is indispensable for another benefit that is paid for; it promises a major therapeutic benefit against an illness that may be fatal or cause severe chronic impairment, with no effective authorised alternative; or it serves post-exposure prophylaxis (Art. 71a para. 1 KVV). The insurer sets the price with the manufacturer.

Continuing a therapy: review by the medical adviser

For therapies ordered by a physician, there is a second form: up to a certain number of sessions, the insurer pays without asking, and after that only if the medical adviser has reviewed a reasoned report and proposed the continuation to the insurer.

The medical adviser advises the insurer and checks whether the requirements for the obligation to pay are met (Art. 57 para. 4 KVG). The medical adviser is independent in their judgement; neither the insurer nor the service providers may give them instructions (Art. 57 para. 5 KVG).

What supplementary insurance pays

In supplementary insurance, cost approval is not a matter of ordinance but of contract. Supplementary insurance is governed by the Insurance Contract Act (ICA); when approval is needed is set out in the general and special terms and conditions of insurance. Typical rules:

• Semi-private or private hospital stay: before admission, hospitals often require approval from the supplementary hospital insurance for the additional costs of the ward.
• Spa treatment, convalescence and rehabilitation: contracts can provide that the insurer only pays if it has authorised the stay in advance.
• Treatment abroad or in a hospital not on the list: the general terms and conditions can require prior approval.
• Expensive outpatient services: for example dental treatment with a cost estimate.

Approval from supplementary insurance is not an administrative decision but a declaration under the contract. In a dispute, there is no objection under the ATSG; the route leads via the insurer, the ombudsperson and, if necessary, a civil court. We are building a comparison of supplementary products under Supplementary insurance. Your insurer’s general terms and conditions and information are decisive.

Conditions

• Before, not after: where the ordinance requires prior approval, it applies before treatment. If treatment starts without approval, the insurer can refuse the costs.
• Complete application: the two-week deadline for medicines only starts once the application is complete (Art. 71d para. 3 KVV). Missing reports delay the decision.
• Only necessary information: the report to the medical adviser may only contain information that is necessary to assess the obligation to pay (Art. 3b para. 2 KLV). The medical adviser only passes on to the insurer’s administration what it needs for the decision (Art. 57 para. 7 KVG).
• Reasons for refusal: if the insurer refuses a medicine, it gives reasons to the physician and the patient (Art. 71d para. 6 KVV). For significant benefits, or if you do not agree, it must issue a written decision (Art. 49 ATSG). You can lodge an objection against it within 30 days; the procedure is free of charge (Art. 52 ATSG).
• Deductible and retention fee: even with approval, you pay the co-payment. The approved costs first count towards the deductible, after which a 10 % retention fee applies up to a maximum of CHF 700 per year, CHF 350 for children (Art. 64 KVG, Art. 103 KVV).
• Invalidity insurance: if you have registered with both the health insurer and invalidity insurance, the health insurer must provisionally grant approval or pay until it is clear which insurance is responsible (Art. 113 KVV).

Sample calculation

Example with fictitious people and assumed costs. Laura is 58 years old and has an optional deductible of CHF 1,500. After an operation, she needs 45 sessions of physiotherapy. CHF 60 per session is assumed; the actual amount depends on the tariff. She has no other medical costs this year. The session limits come from Art. 5 KLV, the deductible and retention fee from Art. 64 KVG and Art. 103 KVV.

The rules of basic health insurance are the same with every insurer. There are differences in service and processing time; you will find key figures on this in the health insurer profiles. You compare premiums in the premium calculator.

How to proceed

1. Ask early: before a planned operation, a longer therapy or an expensive medicine, ask whether approval is needed and who will obtain it.
2. Follow the status: ask your insurer whether the complete application has been received.
3. Keep the approval: approval applies to a specific benefit, duration or number of sessions. Check whether the treatment stays within this scope.
4. Request a written decision if refused: you can only lodge an objection against a written decision. The Office of the health insurance ombudsperson offers help.
5. Plan ahead when switching insurer: if a treatment runs over the turn of the year and you want to switch insurer, make sure beforehand that the new insurer receives the application in good time.

Common mistakes

• Starting treatment before approval has been given. Where approval is required, you are otherwise left with the costs.
• Confusing approval with a cost estimate. The estimate states the price, the approval the insurer’s commitment.
• Treating approval as a blank cheque. More sessions, a different hospital or a different ward require a new review.
• Accepting a verbal refusal. Without a written decision, you cannot lodge an objection.

The page Recognised therapists explains which therapists may bill via the insurer at all, and the page Spitex how nursing care at home is paid for. You will find all benefits in the overview What does health insurance cover?.