What does the mandatory healthcare insurance cover?

Every year, and more specifically between September and December, everyone asks themselves the question: Should I change my health insurance? But most people focus solely on the potential savings they could make, without necessarily knowing what cover they are entitled to. What can we expect from this health insurance? Are we really well covered in the event of a health problem? Are there any gaps in this health insurance?

The aim of this article is to tell you more about the cover to which you are entitled and whether the Health Insurance Act (LAMal) may be insufficient in certain specific cases.

All in all, at FBKConseils we think that health insurance in Switzerland is a good basic insurance: it is fairly general and covers almost all necessary treatments, but as always and as everywhere, it is not perfect.

Let’s not waste any more time and find out what health insurance covers:

Health insurance covers illnesses

I’m not sure we need to dwell any longer on this first chapter, because as its name suggests, health insurance is primarily there to cover you against illness. Which illnesses? All of them, without exception! As soon as you go to see a recognised doctor or specialist and he or she thinks you are ill, all the costs will be covered by health insurance. Whether it’s a cold (hay fever or viral), a back problem or a more serious health problem, you’ll be covered by your insurance.

 As a general rule, everyone gets the care they need to recover from illness.

We’ll see later that when you start to doubt the relevance of a treatment, or when you want to use so-called “alternative” treatments, health insurance can sometimes say no! This is because the fundamental rule described in article 32, paragraph 1 of the LAMal in our Swiss healthcare system is that care must meet three fundamental criteria:

• Economical
• Appropriate
• Effective

The problem is that not everyone has the same view of the effectiveness of a treatment.
So as long as treatments are listed in the Swiss catalogue of treatments, you will be fully insured.

When should we cover ourselves for accidents? 

It’s not always an obvious question, but does health insurance also cover accidents? At first glance, you might be tempted to say “no”, otherwise we would have called it health and accident insurance.

So, in reality, health insurance is not really designed to cover the risk of accident, as this is in principle the duty of your employer. As an employee, the company that hires you must take out accident insurance for each of its staff.

To put it simply, if you have a job, then no, health insurance should not cover you against accidents. But what happens if you don’t have a job?

Actually, there are three different possible cases: 

1. People not in gainful employment: You are unemployed and not looking for a job (student, housewife, retired, other): it is mandatory to include the accident insurance either directly in your health insurance policy, or to go through a third-party insurance to cover this risk. 
2. You are employed less than eight hours per week: your employer must insure you against professional accidents (accidents that occur at the workplace or while on duty). However, it is your responsibility to cover yourself for nonprofessional accidents. 
3. You are unemployed – looking for work: If you are in work and for a certain period of time you do not have a job, the Swiss National Accident Insurance Fund (SUVA) will protect you against accidents.

The accident cover comes at a cost! It is estimated to represent between 7 and 11% in 2024 of the health insurance premium, which amounts to between 360 CHF and 600 CHF per year. It is very important that you make sure you are not insured twice. 

How is maternity covered?

On top of being covered by the mandatory healthcare insurance, maternity is exceptional in Switzerland as no contribution is requested from you in case of a pregnancy. This means no deductible nor quote-part from the 13^th week of pregnancy onward and up until the 8^th week after giving birth. 

Yes, you read that right, you can give birth at a hospital in Switzerland 100% free of charge. But let’s have a closer look at this shall we? 

The list of things covered by the insurance in the context of maternity are the following: 

1. Every complication related to the pregnancy or illnesses that could happen from the 13^th week of pregnancy onwards. 
2. Check-ups (two echography, trimestral tests). 
3. Advice on breastfeeding and preparation for delivering. 
4. Delivery at a hospital or a birth house. 
5. The hospitalisation of your child upon birth is covered by the insurance of the mother. 

I think we can all agree on the fact that our dear LAMal has more than one trick up its sleeve and works pretty well. Yet, some big gaps do exist in the basic insurance. They can all be covered, without any exception, by adequate supplementary insurances.

Conclusion and tips on health insurance cover

It is obviously not possible to change the cover provided by basic insurance, as this is laid down by law. However, there are a number of small things you can do to improve your health insurance cover:

Tip No. 1: Choose your health insurance wisely: Whatever insurance company you choose, you’ll be entitled to the same cover down to the last decimal point, so if you don’t want to pay a franc too much, every September you’ll have the chance to change freely, so do it.

Tip no. 2, exclude accident insurance: It’s not uncommon for our clients to have a premium that includes accident insurance when they are already covered by employers or unemployment insurance.

Tip no. 3: Understand the gaps in health insurance: Although basic health insurance in Switzerland is fairly comprehensive, everyone may have special needs. In certain very specific cases, it may be worth looking into supplementary insurance and insuring the small gaps you find relevant.