How does the LAMal work and who pays for what?

One day or another, everyone will be bound to go pay a visit to a general practician, get treated as an out- or inpatient. No matter the reason, the functioning is the same. (But does everyone have to be affiliated to the same health insurance company? (63))

Once the insurance is purchased, there are only three different types of bills that the insurees can receive.  

Every expense related to your health insurance 

The insurance premium  

In our article explaining how to choose your insurance and at what price (64), you found out about how the price of this cover is calculated. 

Insurance premiums will always have to be paid monthly, per trimester or annually, regardless of whether or not you get health problems during the year. 

The deductible 

On top of your insurance premium, you will have to foot all the bills until you reach the amount of your deductible. In other words, when choosing your deductible, you have to be prepared to spend the amount in case of a health problem. 

If, by misfortune, you had to visit your GP for a health problem and the bill is 500 CHF, then, depending on your deductible, the fee will be on you:

• Your deductible is 300 CHF: you will have to pay 300 CHF. 
• Your deductible is more than 300 CHF (500, 1,000, 1,500, 2,500) then you will pay the bill in full without the help of the insurance. 

For more clarity, do not hesitate to have a look at the example below. 

The quote-part

The quote-part is a part of your medical bills that remains your responsibility to pay, even though your medical expenses exceeded the deductible. 

I already know what you are about to say “But Noé, isn’t this the whole purpose of the deductible? Determining the maximal amount we will have to pay in case of a problem?” 

Yes, yes, you are completely right. But in case of a serious problem leading to costs that are above your deductible, a contribution of up to a maximum of 10% of the medical fees will be asked from you, it is the quote-part. Looks like even the mandatory insurance has gaps (66) … 

However, this quote-part can never exceed: 

• 350 CHF per child, a maximum of 1,000 CHF if you have more than two children within the same health insurance company. 
• 700 CHF for adults. 

So, what do you think? It is not that bad after all, right? 

Let’s use various examples to make things more understandable. 

Say my deductible is 2,500 CHF.

Case 1: this year, my medical costs were of 2,000 CHF. I will therefore have to pay for the whole thing myself. 

Case 2: this year, my medical costs were of 3,000 CHF. I will have to pay 2,500 CHF (my deductible) + 10% of 500 CHF (that is 50 CHF) and pay a total of 2,550 CHF. My insurance will cover the remaining 450 CHF. 

Case 3: this year, my medical costs were of 10,000 CHF. I will have to pay 2,500 CHF (my deductible) + 700 CHF and pay a total of 3,200 CHF. My insurance will cover the remaining 7,800 CHF. Why are the full 10% not added to my bill? Because 10% of 7,500 CHF is 750 CHF, which is more than the 700 CHF maximal annual contribution.

How does the reimbursement of a healthcare insurance work?

The system is available in two models with slightly frightening names but that actually work in a very simple way: the third-party guarantor and the third-party payment. 

What is the third-party guarantor? 

The third-party guarantor is when I receive all the bills at home and I pay for all of them. Once the deductible is reached, I send the exceeding bills (which I will have paid for already) to my insurance and patiently wait to be refunded. 

What is the third-party payment?

The third-party payment is simply the opposite of the third-party guarantor. It is when my insurance receives all my bills, pays for them and then sends me my part. The latter amounts to my deductible and my potential cost contributions. 

How to know which model to use? This depends on two factors: 

• The type of care. There exists four different ones: pharmacy, doctor, hospital, psychotherapy. 
• Your insurance. 

Pharmacy bills 

The following insurance use the third-party guarantor system: Assura, Supra, Sanagate, Sanitas Compact One et Intras.

The other ones use the third-party payment system. 

Doctor bills

In this case, for once, it is more straightforward, since every health insurer uses the same third-party guarantor system. 

In practice, however, some doctors ask their patients if they can send the bill directly to the insurance. 

If it contributes to printing less paper, why not, right? 

Hospital bills

Here, it is even easier. The hospital fees use the third-party payment system, without making any exceptions. 

And it makes sense: the amounts billed being rather high, the deductible is almost always exceeded. So the insurance might as well get the bill directly! 

That being said, insurees, you and I, still have to double check the amount and details (contact details, dates, etc.) on the bill. 

Psychotherapy bills 

In 9 cases out of 10, the third-party payment system is used! In this field, very few insurances have price agreements with Santé Suisse allowing them to offer a third-party payment system.