Does health insurance pay for treatment abroad?

What basic health insurance pays

Basic health insurance is insurance for treatment in Switzerland. In principle, it only pays for compulsory benefits from approved service providers in Switzerland. The law allows the Federal Council to provide for exceptions for services abroad and to limit them (Art. 34 para. 2 and 3 of the Federal Health Insurance Act, KVG). They are implemented in Art. 36 KVV. This results in five cases:

Under Art. 36 para. 2 KVV, an emergency exists if you need treatment during a temporary stay abroad and returning to Switzerland is not appropriate. It does not have to be life-threatening: an infection that cannot wait until you get home also counts. It is not an emergency if you travel abroad precisely for this treatment.

In the 27 EU states, in Iceland, Liechtenstein, Norway and the United Kingdom, international benefits assistance applies. With the European Health Insurance Card on the back of your health insurance card, you receive all services that are medically necessary, taking into account the nature of the service and the expected length of your stay (FOPH). Billing follows the law of the host country, with its co-payments. The liaison body for this billing is the Common Institution under the Federal Health Insurance Act.

Why only 90 % in hospital? In Switzerland, the canton of residence bears at least 55 % of inpatient costs (Art. 49a para. 2ter KVG), and the insurer the rest of no more than 45 %. Abroad, the canton pays nothing. The insurer pays no more than twice its Swiss share, i.e. 90 % of what the stay would have cost in Switzerland.

Transport and rescue: Basic health insurance pays 50 % of medically necessary patient transport, up to a maximum of CHF 500 per calendar year (Art. 26 KLV), and 50 % of rescues, up to a maximum of CHF 5,000 per calendar year, but expressly only for rescues in Switzerland (Art. 27 KLV). Repatriation from abroad is not a benefit of basic health insurance. More on this on the page Patient transport.

Medicines: If you buy medicines abroad, basic health insurance only pays for them if you need them because of an acute illness during the temporary stay (Priminfo, FOPH).

What supplementary insurance pays

What basic health insurance leaves open abroad is only covered by voluntary insurance under the Insurance Contract Act (ICA): supplementary outpatient insurance with a module for abroad, supplementary hospital insurance with worldwide cover or separate travel insurance. The law does not prescribe any benefits for these products. Typical rules cover:

• payment of the difference between the foreign invoice and the upper limit of basic health insurance, often up to a contractual sum,
• transport back or repatriation to Switzerland, usually only with the approval of an assistance centre,
• search, rescue and recovery costs abroad,
• the duration of cover per trip, for example a certain number of weeks,
• exclusions for known pre-existing conditions or planned treatment.

Supplementary insurance may not cover the deductible and retention fee of basic health insurance (Art. 64 para. 8 KVG); it only contributes to the part that basic health insurance does not reimburse at all. We set out the modules of supplementary insurance side by side under Supplementary insurance. What always counts are the general terms and conditions and the information from your insurer.

For stays outside the EU, the FOPH recommends supplementary travel insurance, especially for countries with high treatment costs such as the USA, Canada or Japan. What you can do in practice before and during a trip is explained in the article Ill abroad and on holiday.

Conditions

• Temporary stay: Cover abroad applies to holidays, business trips, language stays and other stays, as long as you live in Switzerland and therefore remain subject to compulsory insurance here (Art. 3 KVG). If you move your residence abroad, other rules apply, see Moving abroad.
• Returning is not appropriate: If the treatment can wait until you return without disadvantage, it is not an emergency. The insurer can check this on the basis of the documents.
• Prior approval for planned treatment: If a treatment is not available in Switzerland, your physician submits a reasoned request to your insurer’s medical adviser (Priminfo). The insurer decides before the treatment. The procedure corresponds to cost approval, see also Cost approval.
• Cross-border programmes: The FOPH can approve programmes in which insurers and border cantons agree that certain services in border regions are paid for (Art. 36a KVV). The services, the approved foreign providers and the tariffs are then set; nobody may be obliged to be treated abroad. You can find out from your insurer whether your insurer and your canton take part in such a programme.
• Giving birth abroad: Except in an emergency, basic health insurance only pays for a delivery abroad if the child thereby acquires the mother’s or father’s nationality or would otherwise be stateless, and then no more than the single Swiss amount (Art. 36 para. 3 and 4 KVV).
• Deductible and retention fee: Services abroad also count towards the deductible (standard CHF 300) and the 10 % retention fee, up to a maximum of CHF 700 a year for adults and CHF 350 for children (Art. 64 para. 2 KVG, Art. 103 KVV). In the EU, EFTA and the UK, the host country’s co-payment is added.
• Accident insurance first: If you are employed and work at least 8 hours a week for the same employer, accident insurance under the UVG is responsible in the event of an accident (Art. 13 para. 1 UVV). It too reimburses medical treatment abroad up to no more than twice the Swiss amount (Art. 17 UVV).

Sample calculation

Example with fictitious people and assumed invoice amounts. Lea, 34, is on holiday in Thailand and has an acute infection. She goes to a clinic twice as an outpatient; the treatment cannot wait until she returns, so it is an emergency. The clinic charges the equivalent of CHF 1,800.00. The same treatment would have cost CHF 600.00 in Switzerland according to the tariff (assumed). Lea has a CHF 300 deductible and has already used it up this year. The rules come from Art. 36 para. 4 KVV and Art. 64 KVG; the supplementary insurance contribution is a contract example.

For a hospital stay outside Europe, the gap quickly becomes larger, because basic health insurance pays no more than 90 % of the Swiss hospital costs there. It never pays for a return flight with medical escort.

How to proceed

1. Check before you travel: Is the European Health Insurance Card on the back of your health insurance card, and is it valid? Does your supplementary insurance cover treatment abroad and repatriation, and for how many weeks?
2. In an emergency: In the EU area, go to physicians and hospitals of the public system and show the card. Outside Europe, if you are admitted to hospital, contact the assistance number of your supplementary or travel insurance, if you have one.
3. Collect documents: You need detailed invoices, the diagnosis, the medical report and proof of payment for reimbursement.
4. Submit: Submit everything to your insurer. It checks basic health insurance first, then any supplementary insurance.
5. Planned treatment: Have your physician submit the request and wait for the insurer’s written approval before you travel.

Common mistakes

• Believing basic health insurance covers the whole invoice worldwide. Outside the EU, EFTA and the UK, it pays no more than twice the Swiss costs, and in hospital no more than 90 %.
• Planning treatment abroad because it is cheaper there. That is not an emergency; basic health insurance pays nothing if the service is available in Switzerland.
• Forgetting about repatriation. Basic health insurance does not cover rescue and repatriation from abroad (Art. 27 KLV).
• Choosing a private clinic in Europe. The European Health Insurance Card applies in the host country’s public system; private providers often do not accept it.
• Not keeping documents. Without a detailed invoice, the insurer cannot calculate the Swiss comparison amount.

Basic health insurance, and with it cover abroad for emergencies, is the same at every insurer, so you can choose it by premium: the premium calculator shows the offers, and you can find dates and forms for switching insurer under Switching health insurer. Other benefits, from glasses to lymphatic drainage, are explained in the overview What does health insurance cover?.