Reimbursement from health insurance fund: What you need to know

Your health insurance fund covers the costs of certain medical treatments – but how exactly does that work? We explain when costs will be reimbursed by the health insurer and what you need to do.

How does health insurance reimbursement work?

If you would like to be reimbursed by your health insurance fund for treatment or a doctor’s visit, you must follow a clear procedure – both for basic insurance and for any supplementary insurance. The most important document is the invoice, which you receive from the provider of the healthcare service, i.e. the hospital, therapist or doctor.

With many service providers, you must first pay the costs in full. You then submit the invoice to your health insurance fund and receive a refund of the amount or part of it if the health insurance fund agrees. The insurer will then calculate the amount that is reimbursable – less the excess and the 10% deductible that you as the insured must pay.

Here is an example with facts and figures:

• You have the usual standard deductible of CHF 300 in Switzerland, and the bill for the visit to the doctor is CHF 500.
  
• You must pay the deductible in full. What remains is a difference of CHF 200.
• Of this amount , the insurer covers 90 percent, and the remaining ten are covered by your deductible.
• After submitting the invoice to the health insurer, you will be reimbursed 90 percent of the CHF 200 – i.e. CHF 180.

Other providers of health services invoice health insurers directly. In this case, as the insured, you will only receive a copy of the invoice for your information and do not need to take any further action. The framework conditions with excess and deductible are the same.

Supplementary insurance allows you to cover additional benefits that are not automatically covered by basic insurance. This includes, for example, visual aids such as glasses and contact lenses, alternative medicine treatments or special dental treatments. In this case too you submit the invoices issued to your insurer and then receive a refund of the contractually agreed portion.

How do I request a reimbursement from my health insurance fund?

The procedure is very simple. Once you have received the invoice after your visit to the doctor, review the document (the services provided and the associated costs should be listed in detail) and then pay the invoice out of your own pocket. In the next step, you submit the invoice to your health insurance fund. There are usually the following options:

• Most health insurance funds offer apps or portals where you can upload your bill digitally. Important: Invoices must be clearly legible.
  
• You can also send the digitized documents to some health insurance funds by email . However, you should first check whether your health insurance really offers this service.
• Of course, you can also send the invoice by mail to the health insurance fund. Some health insurance funds require a completed reimbursement form to be included with the invoice.
• Remember to also submit any prescriptions or medical prescriptions.
• NB: Some health insurers set deadlines for sending invoices or receipts.

Unlike going to a doctor, anyone who visits a hospital for treatment usually doesn’t have to do anything: Hospitals usually submit their patient invoices directly to the patient's health insurance fund. The insurer calculates the excess and the patient’s deductible that is due and then sends an invoice for the outstanding amount.

How long does it take to be reimbursed by the health insurance fund?

When you receive a reimbursement of your medical expenses from your statutory health insurer depends on a number of factors, but on average it is four weeks. Every health insurance fund works differently, and the processes for submitted invoices also differ. Last but not least, the capacity situation of the health insurance fund influences the processing time: In certain periods, it may take longer for you to be reimbursed – for example, at the end of the year, when significantly more insureds than usual submit invoices and receipts for reimbursement.

In addition, the processing of your application depends on how you submit your invoices. While receipts submitted by mail take longer to arrive and don’t always reach the right department once they are received by the insurer, the health insurance fund can process the reimbursement of receipts and invoices submitted online more quickly. In any case, make sure that the documents you submit are complete. If receipts are missing at the time of submission, the health insurance fund must still request the missing information from you.