Is my treatment abroad insured?

Is my treatment abroad insured?

Over the long weekend, I organised a lovely barbecue at home. The festive mood quickly faded when I bit into the bone of a pork chop...

The pain continued for several days, all the way to a foreign country where I finally had to undergo emergency treatment for a dental infection! Of course, treatment abroad is cheaper than in Switzerland, but my health insurance company is quibbling. Will I not be reimbursed?

J., Geneva

Under certain conditions, your health insurance company may refuse to cover your dental treatment abroad. As you are no doubt aware, the conditions for reimbursement of medical services and the authorised providers are governed by the Health Insurance Act (LAMal) and its ordinance (OAMal).

Broadly speaking, the general principle applicable to Swiss residents is that the basic benefits covered by the LAMal are only guaranteed for treatment carried out in Switzerland. It should be noted that article 31 of the LAMal excludes dental treatment that is not linked to a serious illness.

When abroad, a distinction must be made between countries in the euro zone and those outside. Thanks to the Agreement on the Free Movement of Persons, during a temporary stay in the EU/EFTA/UK, you are entitled to receive benefits in kind that are medically necessary in the event of illness, accident or maternity, taking into account the type of care and the expected duration of the stay.

The catalogue of services is governed by the law of the country in which the treatment is carried out. The contribution to costs is governed by the law of that country and must generally be paid locally. The insured person's share of the costs is not reimbursable in Switzerland under the KVG/LAMal.

During a temporary stay outside the EU/EFTA/UK, treatment carried out as a matter of urgency, because a return to Switzerland is not appropriate, is reimbursed up to twice the amount that would have been paid if the treatment had taken place in Switzerland. In the event of a hospital stay, the insurer's cover is limited to 90% for equivalent treatment in Switzerland.

It is also possible to plan non-emergency treatment abroad, for example if the services required cannot be provided in Switzerland. However, prior approval must be obtained from the insurance company after a thorough examination of the case.

For example, in order for dental treatment to be reimbursed abroad following an overflow of gustatory enthusiasm that does not appear to qualify as an accident, the treatment must be necessary and covered by the law of the country of residence if it is part of the EU/EFTA/UK, it must be considered urgent outside these European countries, or it must be planned and authorised treatment linked to a serious illness.