Health insurance refuses to pay: objection and ombudsman

Why is your health insurer not paying?

For basic insurance benefits, the insurer first decides without a formal decision, for example with the benefit statement (Leistungsabrechnung) (Art. 80 para. 1 KVG). Check these points:

• Cost sharing: you pay the deductible (franchise), 10% of the costs above it as co-payment (Selbstbehalt) up to an annual maximum and, for a hospital stay, a contribution (Art. 64 para. 2, 3 and 5 KVG); more in the guide Deductible and co-payment.
• Benefit catalogue: basic insurance may only pay for the benefits provided for in the KVG, and these must be effective, appropriate and cost-effective (Art. 32 para. 1 and Art. 34 para. 1 KVG). What is included is explained in the guides Swiss health insurance and Psychotherapy.
• Bill: under tiers garant, you pay the doctor and are entitled to reimbursement from the insurer; the bill must be detailed and understandable (Art. 42 para. 1 and 3 KVG). More in the guide Tiers garant and tiers payant.
• Old bills: the claim lapses five years after the end of the month for which the benefit was owed (Art. 24 para. 1 ATSG). According to the ombudsman office, submitting the bill already safeguards this deadline; submit bills in a way you can prove and keep the statement.

When does the health insurance ombudsman office help?

If the reason remains unclear, ask the insurer for an explanation; it must in principle advise you on your rights and duties free of charge (Art. 27 para. 2 ATSG). If that does not help, the health insurance ombudsman office advises and mediates neutrally and free of charge, as long as there is no formal decision. The Federal Office of Public Health (FOPH) also names this order.

The ombudsman office is a foundation under private law and is responsible for basic insurance as well as the supplementary and daily allowance insurance of health insurers; it also checks whether cost sharing was charged correctly. You can reach it via the form on om-kv.ch or on +41 41 226 10 10 (advice in German; French: +41 41 226 10 11, Italian: +41 41 226 10 12; Monday to Friday, 9:00 to 11:30).

Contacting it does not interrupt any deadline, and it cannot give instructions to insurers. It does not act, or stops acting, in these cases:

• The insurer has already issued a formal decision, a lawsuit is pending, or the media are involved.
• The amount in dispute is below CHF 100, or you have instructed a lawyer; if you have legal expenses insurance, you only get brief initial information by phone.
• The dispute concerns the doctor or the treatment, approved premiums, decisions by public offices such as on premium subsidies, insurance with no link to health insurance such as household contents or liability insurance, even on the same policy, or other social insurance schemes such as disability insurance (IV).

How do I request a formal decision?

You have the right to request a formal decision from the insurer (Art. 51 para. 2 ATSG), and the insurer must issue it within 30 days (Art. 127 KVV). It is in writing, must give reasons if it does not fully grant your request, and must state the available means of appeal; defective notification must not disadvantage you (Art. 49 para. 1 and 3 ATSG).

The insurer may not make the formal decision, the decision on the objection or your right to appeal dependent on you first going through an internal procedure (Art. 80 para. 3, Art. 85 and 86 KVG). You may be represented, if necessary with free legal counsel (Art. 37 para. 1 and 4 ATSG).

Objection to the formal decision: deadline, form and costs

You lodge an objection against the formal decision within 30 days with the insurer that issued it. The procedure is free of charge; lawyer's fees are generally not reimbursed (Art. 52 para. 1 and 3 ATSG). First the rules on the deadline, then the steps:

• If the deadline ends on a Saturday, Sunday or public holiday of the canton where you or your representative live, it runs until the next working day (Art. 38 para. 3 ATSG).
• Suspension: from the seventh day before to the seventh day after Easter inclusive, from 15 July to 15 August inclusive and from 18 December to 2 January inclusive (Art. 38 para. 4 ATSG).
• The deadline cannot be extended (Art. 40 para. 1 ATSG). If you were prevented through no fault of your own, request restoration of the deadline within 30 days after the obstacle ends and submit the objection at the same time (Art. 41 ATSG).

1. 1Work out the deadline: the 30 days start on the day after delivery (Art. 38 para. 1 ATSG). A registered letter that is not collected is deemed delivered no later than the seventh day after the first delivery attempt (Art. 38 para. 2bis ATSG).
2. 2Content: state what you are asking for (Rechtsbegehren) and give your reasons (Art. 10 para. 1 ATSV).
3. 3Form: in writing with your signature, or orally in a personal meeting, then with minutes that you sign (Art. 10 para. 3 and 4 ATSV). The FOPH recommends the written form.
4. 4Sending: it is enough to hand the objection to Swiss Post on the last day at the latest (Art. 39 para. 1 ATSG). Unlike a cancellation, posting is what counts; registered mail serves as proof but is not required.

What happens after the objection?

The insurer must issue a reasoned decision on the objection (Einspracheentscheid) within a reasonable period (Art. 52 para. 2 ATSG); the law does not set a fixed number of days. If the request, the reasons or the signature are missing, it sets a deadline to correct this (Art. 10 para. 5 ATSV). It can also change the formal decision to your disadvantage, but must first give you the chance to withdraw the objection (Art. 12 ATSV).

Against the decision on the objection, you file an appeal (Beschwerde) within 30 days with the insurance court of your canton of residence (Art. 56 to 60 ATSG); according to the FOPH, only if you lodged an objection first. If the insurer issues no formal decision or no decision on the objection despite your request, you can appeal directly (Art. 56 para. 2 ATSG). You need a brief statement of the facts, a request and brief reasons; the court establishes the facts itself (Art. 61 let. b and c ATSG). In disputes about basic insurance benefits there are no court costs, except for wanton or reckless conduct (Art. 61 let. fbis ATSG).

Supplementary insurance not paying: a different route

Supplementary insurance from health insurers is subject to the Insurance Contract Act (VVG), that is, private law (Art. 2 para. 2 KVAG); the formal decision and objection under the ATSG belong to basic insurance under the KVG (Art. 1 para. 1 KVG). Disputes over supplementary insurance are decided by the courts under the Civil Procedure Code (ZPO), not by the Swiss Financial Market Supervisory Authority.

The simplified procedure applies, regardless of the amount in dispute (Art. 243 para. 2 let. f ZPO). In principle, a conciliation attempt comes first; it is dropped if your canton has designated a single court for these disputes (Art. 7, 197 and 198 let. f ZPO). Court costs arise only for bad-faith or wanton conduct of proceedings (Art. 113 to 115 ZPO). Before the court, but not in conciliation proceedings, the losing party may have to pay the other side's lawyer's fees (Art. 106 para. 1 and Art. 113 para. 1 ZPO). The claim becomes time-barred five years after the fact that gives rise to the obligation to pay, or after two years for collective daily sickness allowance insurance (Art. 46 para. 1 and 3 VVG).

Here too, the health insurance ombudsman office can mediate beforehand. In the easyall calculator, you compare basic and supplementary insurance based on your details and needs; if you have questions, easy, our AI guide, can help.