Problems with health insurance: Who can help in the event of a dispute?

Conflicts with health insurers can be very stressful. The most common problems include incomprehensible invoices and denial of benefits. But there are also often issues between basic and supplementary insurance and when it comes to switching health insurance.

Do you know your rights? And do you know how to enforce them? Only those who are well informed can defend themselves. But sometimes this is not enough. In deadlocked situations, professional help is needed. Contact a patient organization, the ombudsman’s office, or your legal protection insurer.

Our tip: Anyone who takes out supplementary insurance with AXA benefits from a free legal protection service in connection with their health insurance. We support you, for example, in disputes about switching insurers or about rejected invoices.

What should I do if I have problems with my health insurer?

At first annoying, then worrying – and eventually only frustrating: Repeated problems with health insurance take a lot of effort. After all, you want to be able to rely on the fact that the costs of your treatments will be covered. After a long back and forth, you’re at your wits’ end. Before calling in outside help, you can take the following steps:

• Health insurer: Have you studied the insurance contract and conditions carefully and are convinced that you are in the right? Explain your point of view clearly to the health insurer again, in writing. Put forward all the arguments and ask for a written opinion.
• Patient organizations (organized regionally) and SPO - Swiss organization for patients and insured persons (in German): These organizations defend the rights of patients – from clarifying certain treatment errors to disputes with insurance companies. The initial consultation is free of charge.
• Health insurance ombudsman (in German): This independent institution advises and mediates in disputes between insured persons and health insurance funds. It is neutral, free of charge, and an important address if direct discussions with your health insurer have not helped.

Tips for a successful complaint

1. Documentation: Keep everything that is relevant – meeting notes, letters, emails, medical reports, expert opinions, invoices, cost estimates, etc.
2. Clarity: Describe your concern as clearly and precisely as possible. Avoid getting emotional and focus on the facts.
3. Stipulated periods: Make sure you comply with legal and contractual deadlines.
4. Lawyer: Complex matters require support from specialized legal assistance in health insurance law.
5. Perseverance: Complaints cannot always be resolved immediately. Be patient, but persevere until a solution is found.

Which lawyer will help with problems with health insurance?

Problems with health insurance can be complicated and legally challenging. If neither the ombudsman’s office nor patient organizations have been able to help, support from a lawyer specializing in health insurance law will help you to enforce your rights and achieve a fair solution.

What are the lawyer’s fees?

The cost of a lawyer varies and depends on the complexity of the case and the length of the proceedings. It is important to find out in advance about the possible costs and to estimate them realistically. If you have legal protection insurance, this may cover your lawyer’s fees.

What steps are required to take legal action?

If direct dialogue does not bring a solution, you should raise a formal objection to the health insurer’s ruling.

1. Submit an objection: The objection should be made in writing, as a rule within 30 days of receipt of the rejection decision.
2. Reason for objection: Explain why you think the health insurer’s decision is unjustified. Refer to the reasons for rejection and refute them with factual arguments. Attach all relevant documents to support your argument.
3. Request confirmation: Ask for written confirmation that your objection has been received. This way you can prove that you have met the deadline.
4. Lodging a complaint with the insurance court: After you have submitted an objection to the insurance company, you can lodge a complaint with the competent cantonal insurance court.
5. Keep going: If the court’s decision is negative for you, you have the option of filing a complaint with the Federal Insurance Court.

Which insurance covers which benefits?

It is often unclear which benefits are actually covered – and by which insurance. You should therefore be familiar with the insurance conditions.

Basic health insurance

Basic insurance guarantees uniform basic coverage. This means that it covers the costs of medically necessary treatments, medication, hospital stays in a general ward, and certain therapies. The mandatory list of basic insurance benefits includes:

• Doctor’s visits
  
• Emergency treatment
• Prescription drugs
• Operations and hospital stays
  
• Prescribed physiotherapy and rehabilitation. Note: Although these benefits are mandatory, you pay the franchise amount (excess) and deductible out of your own pocket. Your health insurer will take care of the rest.
  

Supplementary insurance

Supplementary insurance covers additional benefits that go beyond basic provision, such as:

• Semi-private or private hospital accommodation
• Alternative medical treatments (e.g. acupuncture, homeopathy)
• Dental treatment
• Glasses and contact lenses
• International health insurance

There is no franchise amount for supplementary insurance Your contract and the General Insurance Conditions specify the portion and/or amount your supplementary insurance will pay for a specific treatment (e.g. 75 percent up to a maximum of CHF 1,500 per year).