Medical emergency

What is a medical emergency?

In health insurance, an emergency is a situation in which treatment cannot wait. The Federal Health Insurance Act (KVG) describes it like this: without immediate treatment, the insured person must fear damage to their health or death, or may put the health of other people at risk. What matters is urgency, not the diagnosis and not the place where you are treated.

The term is important because several restrictions of basic health insurance no longer apply in an emergency. You may go to any hospital, including outside your canton. Restricted models such as the GP model or the HMO model provide for exceptions for emergencies in their conditions. And even if benefits are suspended because of unpaid premiums, the health insurer pays for the treatment.

A separate definition applies abroad: an emergency exists if you need treatment during a temporary stay abroad and returning to Switzerland is not reasonable. It is not an emergency if you travel abroad specifically to be treated.

In everyday language, any visit to an emergency department is called an “emergency”. Whether a situation counts as an emergency in legal terms can, however, make a difference to whether costs are covered, for example in a model with a restricted choice of doctors.

How it works

Cost of treatment. Basic health insurance covers emergency treatment like any other service. You pay the deductible and a 10% retention fee up to the annual maximum.

Choice of hospital. Normally, if you are treated in a hospital outside your canton of residence, the health insurer and the canton cover no more than the tariff of your canton of residence. This limit does not apply in an emergency: the health insurer and your canton of residence cover their shares of the remuneration of the hospital that treats you, and no authorisation from your canton of residence is needed.

Rescue and transport. Basic health insurance contributes 50% of the costs of rescues in Switzerland, up to CHF 5,000 per calendar year. For medically necessary patient transport, for example from one hospital to another, it pays 50%, up to CHF 500 a year. More under transport costs.

Abroad. Basic health insurance covers emergency treatment abroad up to a maximum of twice the amount the treatment would cost in Switzerland. In the EU and EFTA, international benefits assistance with the European Health Insurance Card (EHIC) also applies. Anything above that is covered only by supplementary or travel insurance.

Models. The KVG allows models with a restricted choice of service provider (Art. 41 para. 4 KVG). The rules for emergencies are set out in the conditions of the model: whether you may go straight to hospital, and how and within what time limit you have to report the emergency afterwards.

Insured persons in arrears. Cantons can put people who do not pay their premiums despite debt enforcement proceedings on a list; the health insurer then suspends payment for their treatment. Emergency treatment is exempt from this. More under list of insured persons in arrears.

Legal basis

Art. 64a para. 7 KVG defines emergency treatment: it exists when treatment cannot be postponed because, without immediate treatment, the insured person must fear damage to their health or death, or may put the health of others at risk. Under the same provision, emergency treatment is exempt from the suspension of benefits for insured persons in arrears.

Art. 41 para. 3 KVG governs treatment for medical reasons in a hospital that is not on the hospital list of the canton of residence; except in an emergency, authorisation is required. Under Art. 41 para. 3bis KVG, medical reasons always exist in an emergency.

Art. 36 para. 2 of the Health Insurance Ordinance (KVV) defines an emergency abroad, and Art. 36 para. 4 KVV limits cost coverage to twice the Swiss amount. Art. 25 para. 2 let. g KVG provides for contributions to transport and rescue costs; Art. 26 of the Health Care Benefits Ordinance (KLV) sets 50% up to CHF 500 a year for transport, and Art. 27 KLV sets 50% up to CHF 5,000 a year for rescues in Switzerland.

Example: Ambulance call-out with an invoice of CHF 1,200

Sofia, 41, collapses at home and is taken to hospital by ambulance. The rescue service invoices CHF 1,200 (assumed amount). Under Art. 27 KLV, basic health insurance recognises 50%, i.e. CHF 600. The deductible and the retention fee apply to this amount. The table uses the statutory values.

Situation	Uninsured part	Deductible and retention fee	Sofia pays
Deductible CHF 300, already used up this year	CHF 600	10% of CHF 600 = CHF 60	CHF 660
Deductible CHF 2,500, nothing paid yet this year	CHF 600	CHF 600 goes towards the deductible	CHF 1,200

What this means for you

1. In an emergency, act first. Call the ambulance service or go to the nearest emergency department. The insurance questions come afterwards.
2. Know your model’s conditions. Check in the conditions of your model how to report an emergency. If you forget to report it, the health insurer may reduce its payment under its conditions.
3. Cover rescue costs. Check whether your supplementary insurance covers rescue and transport. Compare health insurers and models in the premium calculator and in the profiles under health insurers.
4. Plan ahead before travelling. In countries with high hospital costs, twice the Swiss tariff is often not enough. More under cover abroad.

If you want to change your model because you often need emergency services, you will find the deadlines under switching health insurer.

Common mistakes

• Treating every visit to the emergency department as an emergency. For the exceptions in your model, what counts is urgency in the legal sense. For non-urgent complaints, the normal route via your GP practice or the telemedicine service applies.
• Believing the ambulance is free. Basic health insurance pays only half, up to CHF 5,000 a year.
• Relying on full cover abroad. Basic health insurance pays at most twice the Swiss costs.
• Not submitting invoices from the emergency department. Even below the deductible it is worth it, so that the amounts are credited.