Does health insurance pay for a second opinion?

What basic health insurance pays

A second opinion is not a separate benefit in basic health insurance. The insurer pays for services that serve to diagnose or treat an illness (Art. 25 para. 1 of the Federal Health Insurance Act, KVG), including examinations and treatments by doctors (para. 2 let. a no. 1). If you have a diagnosis or a planned procedure assessed by a second doctor, that is such an examination. Like every benefit, it must be effective, appropriate and cost-effective (Art. 32 para. 1 KVG).

Free choice in the standard model: for outpatient treatment, you choose among the authorised doctors who are suitable for your illness; the insurer pays at the tariff of the doctor you chose (Art. 41 para. 1 KVG). You do not need a referral for this, not even to see a specialist.

Restricted choice: in the GP model, the HMO model and the telemedicine model, you have limited your right to choose by agreement with the insurer and pay a lower premium in return (Art. 41 para. 4 and Art. 62 para. 1 KVG). The insurer then only has to pay for services that your first point of contact provides or arranges. The statutory compulsory benefits are still insured. How referrals work is set out in the conditions of your model.

No duplicate assessment without reason: the insurer pays for examinations needed for the second assessment. Bring existing images and findings so that nothing is done twice. The insurer may object to repeated examinations without a medical reason as not cost-effective (Art. 32 para. 1 KVG).

What supplementary insurance pays

You do not need supplementary insurance for a second opinion in Switzerland, provided you follow the rules of your model. Supplementary insurance is governed by the Insurance Contract Act (ICA) (Art. 2 para. 2 KVAG), and each insurer sets out in its general terms and conditions of insurance (GTC) what it pays in addition. Possible arrangements include, for example:

• consultations abroad that basic health insurance does not cover,
• free choice of doctor in hospital with semi-private or private hospital insurance,
• the insurer’s own advice or second-opinion services.

Supplementary insurance may not cover the deductible and retention fee of basic health insurance (Art. 64 para. 8 KVG). We are building a benefits comparison of supplementary products under Supplementary insurance. The GTC and the information provided by your insurer are decisive.

Conditions

• Medical reason: the second opinion must serve to diagnose or treat an illness, for example before a planned procedure or after a serious diagnosis (Art. 25 para. 1 KVG).
• Authorised doctor: the second doctor must be authorised to work under basic health insurance and suitable for your illness (Art. 41 para. 1 KVG).
• Model rules: in the GP, HMO or telemedicine model, get a referral from your first point of contact beforehand. Otherwise the insurer may refuse to pay the costs (Art. 41 para. 4 KVG).
• Records: you can request the findings, reports and images from the first assessment from a private practice free of charge; the information is generally provided within 30 days (Art. 25 para. 6 and 7 FADP). For public hospitals, cantonal law applies.
• Deductible and retention fee: the consultation counts towards the deductible; after that you pay a 10 % retention fee of up to CHF 700 per year, or up to CHF 350 for children (Art. 64 KVG, Art. 103 KVV).
• Inpatient procedure: separate rules apply to a hospital stay; prior cost approval is explained on the page Cost approval.

Sample calculation

Example with fictitious people and an assumed invoice amount. Daniel is 55, insured in the standard model and has the standard deductible of CHF 300. He already paid it with his first assessment of the year. Before a planned procedure, he has the recommendation reviewed by a second specialist. The consultation costs an assumed CHF 280.00. The deductible and retention fee are the statutory values under Art. 64 KVG and Art. 103 KVV.

In the GP model, you pay a lower premium, but every second opinion goes through your first point of contact. The premium calculator shows how large the premium difference is where you live. The article Insurance models compared compares the rules of the models, and GP model and specialists answers the question about seeing a specialist.

How to proceed

1. Check your model: look at your policy to see whether you are insured in the standard model or in a model with a restricted choice.
2. Get a referral: in the GP, HMO or telemedicine model, first tell your first point of contact that you would like a second opinion.
3. Request your records: ask for the reports, findings and images from the first assessment and give them to the second doctor.
4. Check the invoice: check whether the insurer has settled the consultation correctly. If it refuses, ask for a written justification; the procedure is described in the article Benefit refused.
5. Adjust your model: you can switch to a model with a restricted choice at any time, but back to the standard model only at the end of the calendar year; your notice must reach the insurer by 30 November (Art. 100 para. 2 and 3 KVV, Art. 7 para. 1 and 2 KVG). The dates are under Deadlines, and an overview of insurers under Health insurers.

Common mistakes

• Going to the second doctor without a referral. In the GP, HMO or telemedicine model, you risk paying the whole invoice yourself.
• Not bringing your records. If findings are missing, examinations may be repeated, and you pay the deductible and retention fee on them.
• Getting the second opinion abroad. Basic health insurance does not pay for it, except in an emergency or if the service cannot be provided in Switzerland.
• Waiting for a second opinion in an emergency. In an emergency, immediate treatment is what counts; how your model handles emergencies is set out in its conditions. A second opinion is intended for decisions that can be planned.

What the insurer contributes towards fitness is on the page Gym membership, and when it pays for lymphatic drainage on the page Lymphatic drainage. If you are planning treatment abroad, read Treatment abroad. You can find all benefits in the overview What does health insurance cover?.