MED_SEN_beratung_DSC_8265.jpg

Claims settlements – Questions & answers

Understanding claims settlements

We are committed to keeping claims settlements as clear and simple as possible and, of course, settling your claims correctly.

When you or your doctor send an invoice to Sanitas, we send you a claims settlement.

The claims settlement shows which costs Sanitas pays and your share of the costs.  We therefore welcome customer feedback on claims settlement documents.

If you have any questions, for example on a charged item, copayment or itemised amounts, please contact your service centre.


Cost reimbursement

There are different ways to reimburse invoices issued for medical treatment. Please see below for important information and explanations.

Cost reimbursement (third-party guarantor)

We receive invoices directly from the healthcare provider (hospitals, doctors, therapists, etc.) and transfer the outstanding amount, provided that direct payment has been contractually agreed. We will then invoice you for your cost share and any “uninsured” amount.

Direct payment (third-party payer)

Under the law (KVG/LAMal), people with health insurance have to pay a share of the costs when they claim for treatment provided by a doctor or hospital or for drugs. The cost share comprises an annual deductible, copayment and hospital contribution. Please see below for important information on these definitions.

Cost share

Under the law (KVG/LAMal), people with health insurance have to pay a share of the costs when they claim for treatment provided by a doctor or hospital or for drugs. The cost share comprises an annual deductible, copayment and hospital contribution. Please see below for important information on these definitions.

Deductible (fixed amount)

Initially you pay the medical costs for medication, visits to the doctor and hospital stays. This initial share of the costs is known as the deductible. As soon as the medical costs exceed your chosen deductible, we contribute towards any further costs. The legal minimum deductible for insured persons aged 18 and over is CHF 300 per calendar year. You can increase your deductible to up to CHF 2,500 on a voluntary basis. If you choose a higher deductible, we reward you with a discount on the premium.

Children (under the age of 18)

There is no legally predefined annual deductible for children. This means that parents only have to pay the amount charged in excess of the treatment costs. However, the parents also have the option to choose a deductible for their child in order to reduce the premiums.

Copayment (percentage calculation)

You pay 10% of any medical expenses in excess of your chosen deductible. The maximum copayment is CHF 700 per year for adults, and CHF 350 per year for under-18s.

The copayment increases to 20% for original drugs for which a cheaper generic is available.

Hospital contribution (fixed amount per day spent in hospital)

During a hospital stay, mandatory health insurance covers the costs of treatment as well as the costs for accommodation and board. All insured persons aged 26 and over must contribute CHF 15 per hospital day towards the cost of accommodation and board. Children and young adults up to the age of 25 do not pay any hospital contributions.

Special cases: maternity and preventive medicine

In special cases, a deductible and/or copayment is not applied:

The cost share does not apply in the case of maternity.

The deductible is not applicable for individual preventive measures in conjunction with the national and cantonal preventive health programmes.

Special case: accident cover

If you have included accident coverage in your health insurance policy, you will also share in the costs. This is in contrast to the obligatory accident insurance that is taken out via the employer.

You will pay a share of the costs also in the event of an accident caused by a third party (third-party liability accident). In this case, you can claim back the cost share from the liability insurance of the person responsible for the accident.

Calculation period for the cost share

The year in which the treatment took place is used as the basis for calculating the cost share rather than the point in time at which the invoice is issued or paid.

Invoicing

If we have not contractually agreed direct payment with a healthcare provider (hospital, doctor, therapist, etc.), the Swiss Federal Health Insurance Act states that the patient is liable to pay, not the health insurer. This is why the invoice is sent to you personally after your appointment.

You pay the invoice issued by the billing party and send us the reclaim voucher. We check the invoice and refund you the insured costs minus your cost share.  

How do I claim benefits?

Send us your reclaim vouchers. You can send them by post using our self-adhesive labels, electronically via our website (only available in German), or you can scan them in quickly and easily using the Sanitas app.

How does electronic invoicing work?

A long number is displayed at the bottom of the reclaim voucher. This is the ESR number. You can enter and submit this ESR number here (information only available in German).

How can I tell whether the doctor has invoiced the correct amount?

Sanitas experts check whether the specified tariffs are correct. However, you should always check the following points: Is the reason for treatment correct? Are the dates of treatment correct? Were the treatments listed on the invoice carried out and the medicines provided?

Sanitas_Hauptsitz.jpg
About Sanitas
Find the service centre responsible for you.
MED_COM_lesen_SANITAS_00254_DSC6184.jpg
Customer portal
The Sanitas customer portal app
Legal notice Publication details