Cost approval

What is a cost approval?

A cost approval (Kostengutsprache in German) is your health insurer’s assurance that it will cover the cost of a specific treatment, medicine or aid before the service is provided. In the law it is usually called “special approval by the insurer”. It gives you and the service provider certainty that the bill will not be rejected afterwards.

The distinction matters: the vast majority of basic health insurance benefits do not require approval. A visit to the doctor, a laboratory test, a medicine on the List of Pharmaceutical Specialties (SL) or an emergency in hospital is paid for by the insurer if the statutory conditions are met. Approval is mandatory only where an ordinance expressly requires it. These are mainly services that are expensive, are paid for only under certain conditions, or go beyond the usual number of sessions. The Federal Department of Home Affairs (FDHA) specifies these services in the Health Care Benefits Ordinance (KLV) and its annexes (Art. 33 KVV).

In supplementary insurance, cost approval is a matter of contract. Hospitals often ask for it before admission to a semi-private or private ward or to a hospital outside your canton of residence. The rules are set out in the general terms and conditions of your supplementary insurance.

A cost approval should not be confused with a cost estimate. A cost estimate is drawn up by the service provider, for example a dentist, and only states what the treatment is likely to cost. Whether and how much of it the insurer pays is decided only with the approval.

How it works

The procedure

1. Application: the treating doctor, hospital or therapist submits an application to the insurer with the diagnosis, the planned treatment and the reasons.
2. Review by the medical adviser: medical information goes to the insurer’s medical adviser, who checks whether the conditions for payment are met (Art. 57 para. 4 KVG). The medical adviser is independent in their assessment and passes on to the insurer’s administration only the information needed for the decision (Art. 57 paras. 5 and 7 KVG).
3. Decision: the insurer decides and informs you and the service provider whether it will cover the costs, to what extent and for how long.
4. Billing: the service is billed within the scope of the approval. The deductible and retention fee apply as for any basic health insurance benefit.

Where basic health insurance requires approval

In addition, there are individual items on the Aids and Appliances List (MiGeL), such as repairs to purchased devices, and other services in Annex 1 to the KLV. The treating provider usually knows whether approval is needed; if in doubt, ask your insurer.

Legal basis

• Art. 57 KVG: tasks and position of medical advisers. They advise the insurer, check whether the conditions for payment are met, are independent and pass on only the information needed.
• Art. 33 KVV: the FDHA specifies the services that are covered only under certain conditions; this is done in the KLV and its annexes.
• Art. 71a–71d KVV: reimbursement of medicines in individual cases, special approval after consulting the medical adviser, decision within two weeks, duty to give reasons for a refusal (Art. 71d para. 6 KVV).
• Art. 3b, 3c, 5, 6 and 18 KLV: procedures for psychotherapy, elective inpatient procedures, physiotherapy, occupational therapy and dental treatment in connection with general illnesses.
• Art. 49 and 52 ATSG: for substantial benefits, or if you disagree, the insurer must issue a written decision; you can lodge an objection against it within 30 days. The objection procedure is free of charge.
• ICA and general terms and conditions: in supplementary insurance, the contract determines when approval is needed.

Example: physiotherapy after an operation

Daniel is 52 and needs physiotherapy after knee surgery. Basic health insurance pays for no more than nine sessions per doctor’s prescription; the first treatment must take place within five weeks of the prescription (Art. 5 para. 2 KLV).

The procedure is similar for medicines used outside their authorisation: the doctor submits an application, the medical adviser assesses the therapeutic benefit, and the insurer must decide within two weeks of receiving a complete application (Art. 71d para. 3 KVV).

What this means for you

1. Ask early. For planned treatment, rehabilitation or expensive medicines, ask whether approval is needed and who will obtain it.
2. Make sure the documents are complete. The insurer’s deadlines often start only once the application is complete. Missing reports delay the decision.
3. Get written confirmation. An approval applies to a specific service, period or number of sessions. Keep it and check that the treatment stays within the approved scope.
4. Ask for a written decision if refused. You can only lodge an objection against a formal decision. The deadline is 30 days.
5. Compare insurers, but correctly. In basic health insurance, the rules are the same for all insurers. Differences lie in service, processing times and supplementary insurance. You will find information on the insurers under health insurers and premiums in the premium calculator.
6. Get help. In a dispute, the Office of the health insurance ombudsperson mediates free of charge.

Common mistakes

• Starting treatment before the approval arrives. Where approval is required, the insurer can refuse to pay the costs without it.
• Confusing approval with a cost estimate. A cost estimate states the price; an approval is the insurer’s promise to pay. In any case, basic health insurance pays for dental treatment only in a few cases.
• Treating the approval as a blank cheque. It applies within the approved scope. More sessions, a different hospital or a different ward require a new review.
• Forgetting supplementary insurance. For semi-private or private hospital stays, hospitals often ask for approval from your supplementary insurance. Clarify this before admission, and do the same for rehabilitation and spa treatment.
• Accepting a refusal given only verbally. If you disagree, ask for a written decision so that you can lodge an objection.

More on the procedure in hospital is explained on the page hospitalisation.