Basic insurance pays a flat rate per case
The health insurance covers 45 percent of the flat-rate costs if the doctor operates patient A.'s knee in a hospital that is on the hospital list of the canton where A. lives. The canton of residence then pays the remaining 55 percent. Basic insurance often requires a patient to undergo preliminary examinations at the doctor's or in the hospital, and these examinations are then borne entirely by the health insurance company. This then sends a confirmation of costs before the operation. After the operation, the outpatient services will be offset, and the agreed deductible will also be offset. An additional 15 francs are added per day for meals; this is known as the hospital surcharge.
The supplementary insurance covers other benefits
If the doctor operates on patient A.'s knee outside the canton in which she is registered and lives, the canton of residence pays 55 percent of the flat rate for hospitals outside the canton. The difference must then be borne by A. himself if she does not have a corresponding additional insurance for the? General department throughout Switzerland? has completed.
Important to know: Not all health insurers conclude the usual contracts with all hospitals, because they are no longer allowed to agree arbitrarily high hospital and doctor tariffs. The decisive factor for a possible reimbursement of costs is always your own contract, which in our example must be available for patient A. Corresponding exclusions can be found in the general insurance provisions. Some policies are designed in such a way that they guarantee that costs will be covered throughout Switzerland, while this is not or no longer the case with other contracts. The costs that are not covered by the additional insurance are ultimately borne by the patient.
If the policy is based on a hospital list, the insurance must cover the agreed benefits. However, only if the hospital in which the insured person is to be operated is actually on the hospital list. If this is not the case, the health insurance does not have to cover the costs. Important tip: Before the operation, the health insurance company gives the cost credit. In any case, this should be waited for before a non-urgent operation is promised. If the health insurance company does not grant the confirmation of costs, the costs for the surgery will be charged to the patient.
Conclusion: Always wait for the cost approval first!
In accordance with these considerations, it is absolutely right for the health insurance company to refrain from assuming the costs for an operation or other treatment. If the services are based on a hospital list or if only the services in hospitals that are on the list for the respective canton of residence are paid for, a free choice of hospital is not advisable. If the operation is not urgent and cannot be postponed, the insured should therefore always ask the health insurance company for the confirmation of the costs and only then make an appointment for the operation. This avoids having to bear the costs yourself.
