How does LAMal health and accident insurance work in Switzerland?
The Swiss healthcare system is structured around a compulsory public plan whose legal base is the LAMal and multiple private supplementary plans whose legal base are the LCA; these are commonly respectively referred to as LAMal and LCA plans. For those that are employed more than eight hours per week by the same employer their accident protection will be transferred from the LAMal plan to a plan whose legal base is the LAA, this plan is included in the work contract and partially financed by the employer. The LAMal and LCA plans are financed individually.
The supplementary private LCA plans are used to improve comfort and to cover the multiple areas that remain unprotected under the public LAMal Swiss health and accident insurance plan.
An annual deductible or excess ranging from CHF 300.- to CHF 2’500.-* must be subscribed to for all LAMal plans. The higher the deductible chosen the lower the monthly premium. On top of this deductible an obligatory LAMal participation of 10% of all medical bills is also applied up to a CHF 7’000.- limit for adults and 3’500.- for children.
All Swiss residents must subscribe to LAMal health and accident insurance from their official day of entry into the country. If this is not done within a three-month period, the resident will be automatically affiliated to one of the 60 approved companies that provide health care plans.
Due to the multitude of options, the complexity of the LAMal Swiss health and accident insurance system, and the potential financial risk taken if certain supplementary plans are not subscribed to this is not a domain to be taken lightly.
Our expert’s recommendation:
The financial security of every family can be put to risk if adequate precautions related to LAMal health and accident insurance in Switzerland have not been taken. A clear understanding of the Swiss healthcare system is required to make the right decisions, so we always advise speaking to an expert, contact us for help.
What health and accident insurance plans are available?
The public LAMal plan includes:
- Inpatient treatment in the public hospital of the canton of residence without free choice of surgeon
- Outpatient treatment in the canton of residence (with or without free choice of doctor)
- Accident insurance for Swiss residents that are not employed more than eight hours per week
- Prescribed medication
- Medical transport (very limited protection)
- Home care to avoid hospitalization
No coverage for adult view and teeth are provided, coverage for international care is poor and medical transport is virtually inexistent. Depending on the option chosen the free choice of specialist and doctor for outpatient treatment can be limited with the LAMal plan and the choice of clinic and operating surgeon is restricted for inpatient treatment. For all adult plans an annual deductible applies and there is a mandatory 10% LAMal participation.
The supplementary private LCA plans:
- Improve and complete existing LAMal coverage
- Cover incidents not covered by LAMal
- Provide the free choice of hospital, private clinic and operating surgeon
- Improve comfort (single or double room facilities)
- Improve accident coverage
- Provide allowances in case of death and invalidity
- Provide daily sickness allowance benefits
- Provide loss of income benefits
- Reduce or eliminate waiting times for medical interventions and surgery
As the LCA plans are private insurance plans the providers request a medical questionnaire and will systematically refuse or establish “reserves” on existing medical conditions.
Our expert’s recommendation:
Certain basic supplementary plans should never be overlooked. To avoid financial strain and unexpected bills that could extend into tens of thousands of francs, additional coverage for the following should always be subscribed to:
.Full medical coverage abroad
.Full medical transport
.Full coverage outside your canton of residence
LAMal health and accident insurance plans in Switzerland only cover stays in the common ward of the public hospital in the Canton of residence and do not enable the patient to choose their operating surgeon or specialist. One must subscribe to a private or semi-private supplementary plan to remain free to choose one’s doctor, operating surgeon, specialist and clinic or hospital.
How does LAA accident insurance work in Switzerland?
For Swiss residents that are employed more than eight hours per week by the same employer accidents and illness are treated separately in the Swiss system.
Employees are covered by the LAA plan provided by their employer, the benefits are:
- Full medical care
- Loss of income benefits if work is interrupted following the accident
- The common or public ward of the Cantonal or recognized hospital without the free choice of doctor, operating surgeon, specialist and clinic or hospital if this option has not been subscribed to by the employer.
Children and those not employed or self-employed are covered by the LAMal, the benefits are:
- Full medical care, less the LAMal deductible and the 10% LAMal participation
- The common or public ward of the Cantonal or recognized hospital without the free choice of doctor, operating surgeon, specialist and clinic or hospital if an LCA plan has not been subscribed to.
In the event of an accident employees will pay less than those that do not work or who are self-employed as they will have no participation to pay.
Our expert’s recommendation:
For those that benefit from an LAA plan we advise them to ask their employer for the telephone number to call in the event of an accident that requires medical attention. To avoid being personally charged for the care a claims number must be provided to the medical provider, so they charge it directly to the company’s LAA plan; the faster the case is declared, the faster the claims number is generated, this will minimize tedious paperwork.
What LAMal deductible should I choose?
The LAMal Swiss health and accident insurance deductible cannot be modified during the calendar year and can be changed for the year to come by 30 November. Choosing a deductible is often an educated guess, the choice can be guided by:
- the beneficiary’s existing health condition
- the frequency with which the beneficiary goes to the doctor
- the medical interventions planned in the coming year
The choice of a deductible can have a serious impact on a couple’s monthly budget, as a low CHF 300.- deductible will cost anywhere between CHF 120.- and 150.- (per person and per month) more than a CHF 2’500.- deductible; the yearly difference for a couple can therefore be over CHF 3’000.-
The deductible decision can also be influenced by the average costs of health care in Switzerland.
As a guideline, for those that have high annual medical costs (over CHF 1’500.-), a low deductible of 300.- can reasonably be considered; for those that rarely go to the doctor or have less than CHF 1’500.- of medical expenses per year a high deductible of CHF 1’500.- or 2’500.- can reasonably be considered. For those not covered by an LAA accident plan capping the deductible at CHF 1’500.- is also a common option, as the LAMal will be covering the two risks of accident and illness. For children the most common option is the 0.- deductible.
Our expert’s recommendation:
Contact us for guidance, a lot of variables can influence this choice.
What value or amount is reimbursed in case of a claim?
For medical care that is recognized by the LAMal health plan only expenses that exceed the yearly deductible and the 10% LAMal participation will be reimbursed.
For supplementary LCA plans two situations apply:
- a complementary plan that offers medical care not provided by the LAMal plan, such as alternative therapy or dental care. Here 0.- or 200.- deductibles often apply.
- A complementary plan that pays everything above the LAMal deductible and LAMal participation for improved medical care, such as private or semi-private hospitalization.
Maternity insurance coverage in Switzerland
Maternity is fully covered in the Swiss system and the future mother benefits from a zero deductible and LAMal participation policy from week thirteen of pregnancy until eight weeks after birth; consultations related to the pregnancy in the first thirteen-week period are also taken into consideration.
Seven examinations and two ultrasounds are automatically covered by the LAMal for a normal pregnancy. These can be performed on prescription or by approved doctors or midwives. Special conditions also apply to women over 35 and all “complicated” pregnancies will be followed on a case by case basis. When in doubt or for those that want additional services contact the health insurance provider to check what they will and won’t cover.
As far as giving birth itself is concerned, the Swiss are open to alternative options. This includes home births, birth house, water birth, etc. Doctors and midwives are available to discuss the options. There is also a small financial contribution for a preparatory class (CHF 150). Three sessions are covered with a professional to discuss breast feeding.
Important: On the LAMal plan women must give birth in the local public hospital in the common ward. For all women who wish to give birth with their own gynaecologist in the hospital or clinic of their choice they must subscribe to a supplementary private or semi-private LCA insurance plan. A nine or twelve month waiting period always applies to this option, so for those who arrive in Switzerland who are already pregnant the birth will automatically take place in the public hospital (or the mother will bear the cost of the private clinic). Contact our expert for guidance.
Newborn health insurance coverage in Switzerland
Newborn insurance coverage is referred to as “prénatale” in French and it should always be subscribed to BEFORE THE BABY IS BORN. The LAMal health insurance plan is public, so no medical questionnaire is required prior to subscription. On the other hand, the LCA supplementary plans are private, and a medical questionnaire is obligatory. The only exception is for policies that are subscribed to before the birth of a child. This means that even if the baby is born with a serious medical condition it will be fully covered if the policy is subscribed to “pre-birth”. Contact our expert to benefit from this advantage.
Extended supplementary LCA coverage that should always be included in the Swiss health and accident insurance plan:
- Full medical coverage abroad
- Medical transport
- Full coverage outside your canton of residence
Extended supplementary LCA coverage that can be added to the health and accident insurance plan in Switzerland:
.Recommended if you choose a high deductible
Add a plan that will refund your deductible if you spend a night in hospital (as in inpatient)
.Recommended if you do not benefit from LAA accident coverage or only have the base LAA
Add a supplementary private accident plan with disability benefits and free choice of specialist
.Recommended if you want to benefit from the free choice of specialist
Add a private or semi-private plan
.Recommended if you want to benefit from the free choice of hospital or clinic
Add a private or semi-private plan
.Recommended if you want to give birth with your gynaecologist with the free choice of clinic
Add a private or semi-private plan
.Recommended if you do regular check-ups, go to fitness classes or follow your nutrition
Add a plan that covers preventive medicine and care
.Recommended if you do sport, hike, cycle, or use a scooter or motorbike
Add a private accident plan with free choice of specialist and hospital to guarantee the best possible care in case of injury.
.Recommended if you suffer from back and joint pain or are stress sensitive
Add a plan that covers osteopathy, massages, and techniques such as acupuncture.
.Recommended if you require dental coverage
Add a dental plan
Glossary of Swiss insurance terms – Health and accident insurance
LAMal
LAMal is the acronym of the French term Loi sur l’Assurance Maladie (health insurance law). It is the law which governs the obligatory universal Swiss health insurance plan.
LCA
LCA is the acronym of the French term, Loi sur le Contrat d’Assurance (Insurance contract law). It is the law which governs the Swiss supplementary health insurance plans.
LAA
LAA is the acronym of the French term, Loi sur l’Assurance Accident (Accident insurance law). All employees who work more than 8 hours per week for the same employer benefit from full accident insurance partially financed by their employer. No deductible or participation applies to LAA accident medical care.
Deductible
The deductible or “excess” is the amount the insurance policy holder will pay out of pocket before the insurance company starts to refund the claim. For Swiss health insurance the deductible (“franchise” in French) is applicable per calendar year and not per case. For adults’ deductibles can be 300, 500, 1’000, 1’500, 2’000 or 2’500. For children the options are 0, 100, 200, 300, 400, 500 or 600.
LAMal participation
On top of the LAMal deductible all patients must pay 10% of their medical expenses up to a CHF 7’000.- limit for adults and 3’500.-* for children.
Average costs of health care
General practitioner: CHF 150 to 300 per visit.
Emergency: CHF 200.- to 350.- per visit
Specialist: CHF 250.- to 400.- per visit
Gynaecologist: CHF 200.- to 400.-
Inpatient (hospitalisation): CHF 2500.- to 5000.- per night
Average medical expenses per year for a man in good health in Switzerland: CHF 750.-
Average medical expenses per year for a woman in good health in Switzerland: CHF 950.-
*Figures at time of publishing, 01/2019.
