Office of the health insurance ombudsperson

What is the Office of the health insurance ombudsperson?

The Office of the health insurance ombudsperson (Ombudsstelle Krankenversicherung) is an independent mediation service for insured persons who are getting nowhere with their health insurer. It clears up misunderstandings, explains statements, examines the insurer’s decisions under the applicable law and intervenes if the insurer has made a mistake. Its advice centre is based in Lucerne; it advises insured persons from all over Switzerland in German, French and Italian.

It is run by a foundation under private law. The health insurers decided in 1991 to create an ombudsperson’s office, and the foundation was set up in 1993. It is managed by a board of seven to nine members from all language regions. It is funded by annual contributions from all social health insurers. According to the office itself, its team of lawyers and benefits specialists is not bound by any instructions.

It is important to distinguish it from other bodies. The ombudsperson is not an authority. Basic health insurance is supervised by the Federal Office of Public Health (FOPH), supplementary insurance by the Swiss Financial Market Supervisory Authority (FINMA). Nor is it a court: disputes about benefits under basic health insurance are ultimately decided by the cantonal insurance court, while disputes about supplementary insurance follow civil procedure. And it is not the ombudsman for private insurance and Suva, which deals with household contents, liability or life insurance and with disputes with accident insurance.

How it works

When you can contact it

The ombudsperson is responsible if you have an insurance relationship with your health insurer in one of these areas:

• basic health insurance under the Federal Health Insurance Act (KVG),
• supplementary insurance under the Insurance Contract Act (ICA) offered by a health insurer,
• daily sickness allowance insurance under the KVG or the ICA.

Typical issues include a failed switch of health insurer, unintended double insurance, a premium surcharge for joining late, cancellation of a supplementary insurance policy because health questions were answered incorrectly, an incomprehensible statement of the deductible and retention fee, or a refused benefit.

When it is not responsible

• for disputes with doctors, hospitals or other service providers,
• for reviewing premiums approved by the FOPH,
• for premium subsidies or supplementary benefits paid by the canton or municipality,
• for other social insurance schemes such as invalidity insurance (IV), accident insurance or occupational pension funds,
• if the insurer has already issued a written decision, court proceedings are pending or the media are involved in the case,
• if you have already instructed a lawyer; if you have legal expenses insurance, you only get brief initial information.

How an enquiry is handled

You submit your concern via the web form, by post or by phone. The ombudsperson establishes the facts, usually with documents such as your policy, statements and correspondence. You then either receive a legal assessment, or the ombudsperson contacts your health insurer and forwards its reply to you. Advice is free; cases involving an amount in dispute of less than CHF 100 are not accepted.

Legal basis

The ombudsperson’s office itself has no legal basis in the KVG. It is a foundation under private law that the health insurers set up voluntarily and fund. Its responsibilities and rules (free of charge, amount in dispute of at least CHF 100, no mediation after a written decision) are set out on its own website, linked under “Sources”.

By contrast, the formal procedure, which remains available alongside the ombudsperson, is governed by law. In basic health insurance, the Federal Act on the General Part of Social Insurance Law (ATSG) applies. Under Art. 49 para. 1 ATSG, the insurer must issue a written decision on benefits and claims you disagree with. Under Art. 51 para. 2 ATSG, you can request such a decision. Under Art. 52 para. 1 ATSG, you lodge an objection to the decision with the insurer within 30 days; under para. 3, the procedure is free of charge. Under Art. 56 and Art. 60 ATSG, you can appeal against the decision on the objection to the cantonal insurance court within 30 days.

Art. 85 and Art. 86 KVG prohibit insurers from making an objection or appeal dependent on an internal complaints procedure. Under Art. 34 of the Health Insurance Supervision Act (KVAG), supervision of the implementation of basic health insurance lies with the FOPH. Supplementary insurance is governed by the ICA; there is neither a written decision nor an objection procedure.

Example: a failed switch of health insurer

Nadia, 52, gives notice on her basic health insurance in good time for 1 January and takes out a policy with a new insurer. In January, her old insurer keeps sending her premium bills: it says it refused to let her leave because premiums were still outstanding. Nadia is now insured with two insurers and receives two premium bills every month.

Date	Step
12.01.	Nadia asks the old insurer in writing for a justification.
26.01.	The insurer cites an unpaid bill that Nadia can prove she has paid.
28.01.	Nadia submits the case to the ombudsperson with her notice of cancellation, proof of payment and correspondence.
February	The ombudsperson intervenes with the old insurer.
March	The old insurer confirms her departure as of 31.12. and refunds the premiums paid twice.

The person and dates are fictitious. How to switch correctly is explained under switching health insurer, and a template for your notice of cancellation under cancellation letter.

What this means for you

The ombudsperson is the second step, not the first. This is how to proceed:

1. Ask your health insurer first. Many problems can be solved with a phone call or a letter to customer service. Ask for a written justification.
2. Collect documents. Your policy, statement of benefits, bills, confirmation of cancellation and all correspondence so far.
3. Check responsibility. Does it concern your health insurer and basic, supplementary or daily allowance insurance? Is the amount in dispute more than CHF 100? Has no written decision been issued yet?
4. Submit your enquiry. Via the form on om-kv.ch, by post or by phone.
5. Keep track of deadlines yourself. If you receive a written decision during mediation, lodge an objection within 30 days, regardless of what the ombudsperson does.

If you are generally unhappy with your health insurer, you can switch. You can find the profiles of all insurers under health insurers and the dates for switching under deadlines. If the issue is a suspension of benefits because of unpaid premiums, the ombudsperson can help clarify whether the insurer acted correctly.

Common mistakes

• Waiting for the ombudsperson and missing the deadline for an objection. The 30 days run from delivery of the written decision, even if the case is with the ombudsperson.
• Bringing a dispute with a medical practice. The ombudsperson is not responsible for bills or treatment errors by service providers.
• Trying to challenge the premium. Premiums are approved by the FOPH; the ombudsperson does not review their amount.
• Making an enquiry without documents. Without your policy, statements and correspondence, the ombudsperson cannot establish the facts.
• Instructing a lawyer at the same time. As soon as you are represented by a lawyer, the ombudsperson no longer deals with your case.