Health Insurance: Disputes and Remedies in Switzerland

Disputes with Health Insurance

Disputes with mandatory health insurance (HIA) are frequent in Switzerland. The law provides specific remedies.

Common Grounds for Dispute

The most common disputes concern:

1. Refusal to cover a treatment
2. Challenging the premium amount
3. Changing insurer despite premium arrears
4. Coverage of off-list medications
5. Reimbursement of care received abroad

Decision Procedure (Art. 49 GSLA)

The health insurer must issue a formal decision when refusing a benefit or modifying an ongoing benefit. This decision must be reasoned and indicate the remedies available.

Objection (Art. 52 GSLA)

The first remedy is an objection to the insurer itself, within 30 days of notification of the decision. The objection is free of charge and allows the insurer to reconsider its decision.

Appeal to the Cantonal Insurance Court

If the objection is rejected, an appeal may be filed with the cantonal insurance court within 30 days (art. 56 GSLA). The procedure is in principle free for the insured in mandatory health insurance matters.

Appeal to the Federal Supreme Court

The cantonal judgment may be appealed to the Federal Supreme Court within 30 days (art. 82 et seq. FSCA). The appeal is only admissible if the amount in dispute reaches CHF 30,000 or if the case raises a legal question of principle.

Premium Arrears

In case of non-payment of premiums, the insurer may:

1. Suspend coverage of non-urgent care (art. 64a HIA, depending on the canton)
2. Pursue the debtor through debt collection proceedings
3. Place the debtor on a cantonal list of insured persons in arrears

Changing Insurer

The insured may change health insurer on 1 January each year (cancellation deadline: 30 November). With a deductible above CHF 300, a change is also possible on 1 July.