(last amended on 1 April 2009)
A. CONTRACT/POLICY
1. Do I have to take out supplementary health insurance with the same insurer as my basic insurance?
No. These are different insurance policies that can be taken out independently of one another.
2. What advantages and disadvantages are there of having basic and supplementary health insurance coverage with two different insurance providers?
One disadvantage is that every time a policyholder files a claim they have to determine who will pay the invoice. One financial advantage might be the option of transferring basic insurance coverage to an insurance provider offering more favourable terms.
3. Do requirements apply concerning the term of an insurance contract?
No, the term of the contract is agreed between the insurer and the client. Terms between one and five years are customary. The contract is automatically renewed as long as the policyholder does not cancel the policy within the notice period.
4. Does a health insurance product have to satisfy certain requirements with regard to the benefits offered by it or are insurers free to design a product as they please?
The Insurance Contract Act (ICA; SR 221.229.1) does not specify any benefits that health insurance must provide, meaning that health insurers are free in principle to design their products as they see fit. However, when developing a product the absolute and relatively binding provisions of the ICA (cf. art. 97 and 98) apply.
5. Are permanent exclusions possible with regard to pre-existing conditions?
Yes, however they have to be specifically indicated in the contract documents.
6. Is it possible for different generations of general insurance terms and conditions to be in effect in parallel?
Yes. However, according to art. 35 of the ICA a policyholder has the right to have the contract continued under the new conditions.
B. PREMIUMS
7. Does FINMA publish the premiums of supplementary insurance companies?
No, for two reasons:
There are approximately 1000 products on the market providing for a wide range of benefits. Listing premiums without providing any information on the benefits offered would be of only limited value. Plus which, supplementary insurers are free to decide whether they want to conclude a contract with an interested party; only basic insurance providers are forced to accept applications for coverage made with them. Consequently, a premium table would only be of limited assistance in selecting an insurer.
8. If basic and supplementary insurance premiums continue to go up I will no longer be able to afford any coverage. What options do I have for reducing my premiums?
The premiums for basic and supplementary insurance can be reduced by increasing one’s deductible (excess), i.e. the amount one must pay out of one’s pocket before insurance costs are assumed by the insurer. Other options would be scaling back benefits, such as switching from a private room to a semi-private room, or from a semi-private room to the “general ward throughout Switzerland” option for in-patient treatment. Since supplementary insurance is not compulsory a policy can be cancelled without any further ado.
9. May a supplementary insurance provider raise its premiums if I take out my basic insurance coverage with another insurer?
Some supplementary insurers offer discounts for supplementary coverage only if the policyholder also has a basic insurance policy with them. Administrative fees or minimum premiums may also be imposed if the basic insurance policy is cancelled. You are advised to inquire with the supplementary insurer before making any final decision about cancelling your policy.
10. May premiums be adjusted during the term of a contract?
Yes, assuming the general insurance terms and conditions provide for this, which is usually the case. Premium adjustment clauses of this type are permitted by FINMA for solvency maintenance reasons. A premium adjustment clause specifies that a policyholder has to be informed of the premium adjustment in a timely manner prior to the adjustment going into effect (25–30 days). If the policyholder does not agree to the premium adjustment they have a right to cancel the policy; cancellation is governed by the applicable provisions in the insurance terms and conditions. If the policyholder does not invoke their right, they are deemed to have accepted the adjustment. Any proposed change in rates must be submitted to FINMA prior to going into effect for review by it.
C. AMENDMENTS TO THE INSURANCE CONTRACT/POLICY
11. May my insurer cancel my supplementary insurance policy if I cancel my compulsory basic insurance with it and take out coverage with another insurer?
No. Any cancellation of the supplementary insurance policy on these grounds is prohibited by law.
12. May an insurer cancel my policy if I submit a claim?
Almost all insurance carriers waive this right in their general insurance terms and conditions although the ICA grants both contracting parties, the insurer and the policyholder, the right to cancel. The general insurance terms and conditions of the contract apply. In any event the policyholder has the right to cancel a policy when submitting a claim, by the time benefits are disbursed at the latest.
13. My insurance carrier is offering me a more modern product in lieu of my present insurance. Do I have to accept this offer?
Taking out a new policy is subject to the policyholder’s express consent. If the policyholder refuses to give their consent, the insurance carrier must continue the policy under the existing terms in effect.
An exception to this applies in cases where the insurer revises its existing products by amending the terms and conditions of the contract. The insurer may offer policyholders the option of continuing their existing insurance policy under the new conditions. As long as the new conditions are not disadvantageous to the policyholder, the policy is considered to be accepted, unless the policyholder expressly rejects the new conditions. In the case of new products, or if a revised product contains changes for the worse, a new policy is not valid unless the policyholder gives their consent.
14. May an insurance carrier make changes to the insured benefits provided under an existing policy?
As a general rule, no, since contract amendments in private insurance are subject to the express consent of both contracting parties. However, an insurance carrier can specify in the general insurance terms and conditions that the details concerning benefits (approved therapists or therapies, etc.) are listed in a separate annex. It may make changes to this annex so as to adapt to changes in the group of approved health care providers or to reflect new medical developments; in this case the policyholder has no cancellation right. Clauses are also permissible that provide for necessary amendments to the general insurance terms and conditions associated with new medical developments, particularly when changes are made to the statutory benefit catalogue for compulsory health insurance coverage. As in the case of premium adjustments, a policyholder has the right in this case to cancel the policy. These exceptions enable ongoing adaptation to medical developments in a simple manner. In addition, the insurer may use this to influence health care providers so as to ensure the quality of the services provided by them, for instance, or to counter excessive fee for services demands. Generally speaking, the amount of the premiums must always be justified by the scope of insured benefits provided; changes may not be used to unduly impact the setting of premiums.
D. FURTHER INFORMATION
15. Where can I obtain more information / advice?
For advice and mediation in disputes with health insurance providers and supplementary insurers, please contact the Health Insurance Ombudsman:
Health Insurance Ombudsman
Morgartenstrasse 9
6003 Lucerne
Phone: +41 (0)41 226 10 10
Fax: +41 (0)41 226 10 13
info@ombudsman-kv.ch
16. Who can I contact at FINMA if I have further questions?
questions@finma.ch or tel. +41 31 327 91 00