A young mother confronts the LAMal

A young mother confronts the LAMal

My wife is a few months pregnant with our first child. She is insured with a major local company, which has just billed her for the first two ultrasounds carried out in the twelfth week of pregnancy because it refuses to cover them, on the grounds that the excess has not been reached. However, we are sure that we have read that maternity costs are exempt from the excess and the 10% contribution.

What exactly is the situation?

J&M

You're right to think that maternity costs are fully covered by basic insurance!

Article 29 of the Swiss Health Insurance Act (LAMal) states that compulsory basic health insurance covers not only benefits relating to illness, but also those specific to maternity. Although it is clear that pregnancy is clearly not an illness, this is the solution found by the legislator after the Swiss people rejected the adoption of insurance specifically dedicated to maternity.

The benefits covered by the KVG/LAMal include check-ups carried out by a doctor or midwife or prescribed by a doctor, during and after pregnancy, childbirth at home, in a hospital or in a birthing centre, as well as the assistance of a doctor or midwife, advice on breastfeeding and care for a healthy newborn baby as long as it remains in hospital with its mother.

In principle, insured persons contribute to the costs of the benefits they receive, as stipulated in art. 64 of the LAMal. The contribution comprises a fixed amount per year, known as the excess, and 10% of costs in excess of the excess (co-payment). There is, however, one exception to this rule: no contribution to costs may be levied for check-ups carried out by a doctor or midwife (or those prescribed by a doctor) during and after pregnancy, and for benefits and care in the event of illness provided from the 13th week of pregnancy, during childbirth and up to eight weeks afterwards.

It should be noted that until 2014, only the specific maternity services without complications listed above were exempt from co-payment, i.e. essentially examinations, childbirth, breastfeeding advice and newborn care. Complications, on the other hand, were considered as illnesses subject to the aforementioned contribution. Since the revision of the law that came into force that year, medical costs incurred by a pregnant woman from the 13th week of pregnancy until 8 weeks after giving birth have also been exempt from co-payment.

Mums-to-be who do not have a complicated pregnancy should therefore be adamant that their check-ups should be covered, as some insurance companies are more cheerful and responsive than others when it comes to announcing a happy event...