Disputes with LAMal Health Insurance in Switzerland
The Federal Act on Health Insurance (LAMal/KVG) of 18 March 1994 guarantees every person domiciled in Switzerland a mandatory minimum coverage for medical care. Despite this protective legal framework, disputes between insured persons and health insurers are frequent: reimbursement refusals, disputes over the choice of doctor, disagreements on covered costs, questions of deductible and co-payment. PBM Avocats represents insured persons in Geneva and Lausanne in these proceedings.
Benefits Covered by Basic LAMal Insurance
Basic LAMal insurance covers benefits that are effective, appropriate and cost-effective (EAE) as defined by the Federal Council. The main reimbursed benefits are:
- Outpatient care: medical consultations, analyses, medications listed on the specialties list (LS)
- Hospital care: hospitalisation in shared accommodation at a hospital in your canton of domicile or at a hospital on the LAMal list
- Maternity care: without deductible for childbirth and prenatal check-ups
- Physiotherapy: on medical prescription, according to the OPAS
- Dental care: only in case of serious and unavoidable illness (art. 31 LAMal)
- Medications: listed on the FOPH specialties list
Main Grounds for Disputes with LAMal
| Grounds for Dispute | Legal Basis | Means of Challenge |
|---|---|---|
| Refusal to reimburse a treatment | Art. 25 et seq. LAMal, OPAS | Objection within 30 days |
| Refusal to cover out-of-canton care | Art. 41 LAMal | Objection then cantonal appeal |
| Dispute over deductible or co-payment | Art. 64 LAMal | Objection within 30 days |
| Non-payment of premiums / termination | Art. 64a LAMal | Objection then arbitration tribunal |
| Contested medical tariffs | Art. 44 LAMal, TARMED | Cantonal arbitration tribunal (art. 89) |
| Refusal to cover a medication | Art. 25 para. 2 let. b LAMal, LS | Objection + medical adviser opinion |
Deductible and Co-payment: Understanding Your Contribution
Each insured person bears part of the medical costs:
- Ordinary deductible: CHF 300 per year (adults). Higher optional deductibles (up to CHF 2,500) allow for reduced premiums
- Co-payment: 10% of costs beyond the deductible, with an annual maximum of CHF 700 for adults (CHF 350 for children)
- Hospital contribution: CHF 15 per day of hospitalisation (at the expense of the adult insured)
These amounts are verified annually and may be challenged if the insurer calculates them incorrectly.
The Objection Procedure Against a LAMal Refusal
Any decision by a LAMal health insurer may be subject to an objection within 30 days (art. 52 ATSG/LPGA). The objection must be addressed to the insurer in writing and state the grounds for challenge. The insurer then has a deadline to rule on the objection.
If the objection is rejected, the insured may apply to the cantonal insurance court within 30 days. In Geneva, the competent court is the Cantonal Court of Social Insurance (ATAS). These proceedings are in principle free of charge for the insured.
Supplementary Insurance (LCA/ICA) and Basic Insurance (LAMal): Important Differences
It is essential to distinguish:
- Basic LAMal insurance: governed by federal public law; mandatory minimum benefits; disputes before social insurance courts
- Supplementary insurance (LCA/ICA): governed by the Insurance Contract Act; contractual benefits; disputes before ordinary civil courts
Disputes relating to supplementary insurance (private room, alternative medicine, extended dental care, etc.) follow different rules and are handled under private contract law.
Cantonal Subsidies for LAMal Premiums
Persons in difficult economic circumstances are entitled to premium reductions (subsidies) according to their financial situation. These subsidies are financed by the cantons and granted according to cantonal rules. In Geneva (OCAS) and Vaud (SPSAS), applications may be filed. A refusal of subsidies may also be challenged by way of objection.
Can LAMal health insurance refuse a reimbursement?
Yes. LAMal only covers benefits that are effective, appropriate and cost-effective (EAE). An insurer may refuse to reimburse a treatment not listed in the official catalogues (LiMA, OPAS), performed outside the treating physician's practice without a prescription, or deemed not cost-effective. The refusal must be the subject of a written reasoned decision subject to objection.
What is the deadline to challenge a LAMal reimbursement refusal?
You have 30 days to file an objection with your health insurer. After this deadline, the decision becomes final. If the objection is rejected, you may appeal within 30 days before the competent cantonal insurance court (ATAS in Geneva, Cantonal Court in Vaud).
What should I do if my health insurer terminates my contract for non-payment?
Termination for non-payment of premiums is possible under LAMal. However, even in the event of termination, you remain covered for urgent treatments. In case of financial difficulties, you may request a payment plan or health insurance subsidies from the canton. A lawyer can help you find solutions before termination.
Can my doctor charge rates higher than the LAMal TARMED rates?
For basic LAMal coverage, the doctor cannot charge beyond the official TARMED rate. If you have supplementary insurance (LCA/ICA), rates may differ. Unauthorised excess charges may be contested with the insurer and, if necessary, before the cantonal arbitration tribunal (art. 89 LAMal).
How can I challenge an imposed change to my LAMal insurance model?
Insurers cannot unilaterally modify your insurance model without your agreement. However, they may adapt premiums and insurance conditions according to the legal rules. Any change must be notified to you with a notice period. If you believe the conditions have been illegally modified, contact a specialist lawyer.