Does health insurance pay for the dentist?

What basic health insurance pays for

In Switzerland, dental treatment is an exception in the catalogue of benefits: basic health insurance does not pay for it as a matter of principle, but only in the cases named in Art. 31 of the Federal Health Insurance Act (KVG). The idea behind this: caries and gum inflammation are considered largely avoidable. Exactly which diseases are meant is listed exhaustively in Art. 17 to 19a of the Health Care Benefits Ordinance (KLV). Anything not on this list belongs to ordinary dental costs, which you bear yourself.

For diseases of the masticatory system, there is an additional limit: the condition must reach the level of an illness, and the insurer only pays for as much treatment as that illness requires (Art. 17 KLV). Basic health insurance pays for general anaesthesia if covered dental treatment is not possible without it, and for other dental treatment only because of a severe mental or physical disability (Art. 19b KLV).

A dental accident is a special case. Basic health insurance covers damage to the masticatory system after an accident, but only to the extent that no accident insurance pays for it (Art. 1a para. 2 let. b KVG). Employees who work at least 8 hours a week for the same employer are also insured under the Accident Insurance Act (UVG) in their free time (Art. 13 of the Accident Insurance Ordinance, UVV). Accident insurance then pays for the treatment by the dentist (Art. 10 UVG), without the health insurer’s deductible and retention fee.

For congenital disorders, invalidity insurance (IV) takes precedence until the age of 20 (Art. 13 of the Federal Act on Invalidity Insurance, IVG). Under Art. 19a KLV, basic health insurance only pays if the treatment is needed after the age of 20 or if the person is not insured with the IV.

What supplementary insurance pays for

Check-ups, dental hygiene, fillings, root canal treatment, crowns, bridges and implants are only paid for by voluntary dental insurance. It is supplementary insurance under the Insurance Contract Act (ICA), and the law does not prescribe any benefits there. Each insurer sets out in its general terms and conditions:

• what percentage of the bill it covers,
• up to what maximum amount per calendar year it pays,
• whether waiting periods apply before expensive treatment is insured,
• whether orthodontics, implants or dental accidents are included,
• whether it requires a dental examination before you take it out.

Unlike in basic health insurance, with dental insurance the insurer may ask health questions, exclude existing damage with a reservation or reject your application. You must answer the questions completely and truthfully (Art. 4 ICA). The contract therefore usually does not cover treatment that is already foreseeable when you take it out.

We are building a comparison of the benefits of supplementary products under Supplementary insurance. Which insurers offer which products is shown in the health insurer profiles. What always counts are the general terms and conditions and the information from your insurer.

Conditions

• Covered case: The insurer checks whether your treatment falls under one of the items in Art. 17–19a KLV. The diagnosis alone is not enough; the condition must reach the required level of severity.
• Authorised dentist: Only dentists authorised for benefits under Art. 31 KVG may bill basic health insurance. They need a cantonal licence to practise, three years of practical experience and must meet the quality requirements (Art. 42 of the Health Insurance Ordinance, KVV).
• Approval in advance: For dental treatment due to a severe general disease, the insurer only pays with prior special approval that takes into account the recommendation of the medical adviser (Art. 18 para. 2 KLV). In the other cases, too, it is worth submitting a cost estimate to the insurer before major work.
• Deductible and retention fee: If basic health insurance pays, the bill first counts towards the deductible; after that you bear a 10 % retention fee up to a maximum of CHF 700 a year, for children up to CHF 350 (Art. 64 KVG, Art. 103 KVV).
• Other insurance first: In the event of an accident, accident insurance pays first; for congenital disorders up to the age of 20, the IV. Basic health insurance only steps in if these are not responsible.
• Supplementary benefits: If you receive annual supplementary benefits to old-age and survivors’ insurance (AHV) or invalidity insurance (IV), the canton reimburses documented costs of dental treatment (Art. 14 para. 1 let. a of the Federal Act on Supplementary Benefits, ELG). The cantons may limit reimbursement to cost-effective and appropriate treatment; ask the supplementary benefits office before major work.

Sample calculation

Example with fictitious people and assumed invoice amounts. Martin is 52 and has the standard deductible of CHF 300. Before planned chemotherapy, he needs to have his teeth restored; this is a case under Art. 19 let. c KLV. In the same year, he has two fillings done. He has no other medical bills in the year yet. The deductible and retention fee are the statutory values from Art. 64 KVG and Art. 103 KVV.

Altogether, Martin bears CHF 870.00 of CHF 1,680.00. The co-payment from the restoration counts for all further benefits of basic health insurance in the same year: his deductible is used up, and he has reached CHF 90 of the CHF 700 maximum retention fee. The fillings do not count towards this, because basic health insurance does not cover them.

How much you bear in deductible and retention fee over the whole year depends on your deductible. You calculate the break-even point between a low and a high deductible in the deductible calculator, and you compare premiums in the premium calculator.

How to proceed

1. Clarify the diagnosis: Ask your dentist whether your treatment could fall under Art. 17–19a KLV, for example because of upcoming chemotherapy or a jaw disease.
2. Submit a cost estimate: Submit it to your insurer before treatment begins. For general diseases, approval is mandatory.
3. Report an accident: Report a dental accident immediately, as an employee to your employer, otherwise to your health insurer. If you are insured against accidents through your employer, you can exclude accident cover from your health insurance; whether this is possible for you can be checked under Excluding accident cover.
4. Submit the bill: Dentists usually send the bill directly to you (tiers garant, i.e. you pay and claim reimbursement). Submit it to basic health insurance if there is a covered case, otherwise to your dental insurance.
5. Keep records of costs you bear yourself: They may be tax-deductible as medical expenses. For direct federal tax, only the part above 5 % of the relevant income counts (Art. 33 para. 1 let. h of the Federal Act on Direct Federal Taxation, DBG). More on this in the article Deducting medical expenses from taxes.

Common mistakes

• Expecting basic health insurance to pay for caries. Fillings, root canal treatment and crowns due to caries are not insured.
• Forgetting the approval. For general diseases, the insurer does not pay without prior approval (Art. 18 para. 2 KLV).
• Not reporting the dental accident. Without a report, there is no proof that an accident occurred.
• Only taking out dental insurance when the tooth hurts. Insurers generally exclude known damage.
• Bypassing the IV. For children with a congenital jaw or dental condition, first clarify whether the IV is responsible.

Teeth cleaning is covered in the article Dental hygiene, the cost of braces on the page Braces. When dental insurance for children is worthwhile is explained under Dental insurance for children. All other benefits are in the overview What does health insurance cover?.