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Old 13.05.2014, 13:12
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Please help, advice needed on insurance coverage on pregnancy

I'm hoping someone can help us with our insurance confusion. I unfortunately had to have a d&c (abortion) in February as we lost the heartbeat of our baby in the 10th week. To cut a very long story short, our insurance provider sanitas informed us today that they will not be liable to pay for the operation which is nearly 2000chf because there is a new law in Switzerland that only makes them responsible after 13 weeks. They have basically told us it was our decision to have the operation so we are liable, it's the law. How can this be right? The consultant told me my options were possibly bleed to death or have the op- not much of an option! They are basically grouping us with people that elect to have this operation, which if I'm honest, I find heartless and insulting! Can there really be no distinguishing features between my case and that of someone who doesn't want a baby?
If anyone could give us any help or advise we'd be very grateful. This is not the kind of stress we need after such a rough few months!
Thanks in advance,
Natasha
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Old 13.05.2014, 13:15
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Re: Please help, advice needed on insurance coverage on pregnancy

There is a medical Ombudsman, maybe he can help you. https://www.ch.ch/en/ombudsman-service/

I asked for Zermatt: https://secure.om-kv.ch/html/aufgabe.html
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Old 13.05.2014, 13:18
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Re: Please help, advice needed on insurance coverage on pregnancy

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I'm hoping someone can help us with our insurance confusion. I unfortunately had to have a d&c (abortion) in February as we lost the heartbeat of our baby in the 10th week. To cut a very long story short, our insurance provider sanitas informed us today that they will not be liable to pay for the operation which is nearly 2000chf because there is a new law in Switzerland that only makes them responsible after 13 weeks. They have basically told us it was our decision to have the operation so we are liable, it's the law. How can this be right? The consultant told me my options were possibly bleed to death or have the op- not much of an option! They are basically grouping us with people that elect to have this operation, which if I'm honest, I find heartless and insulting! Can there really be no distinguishing features between my case and that of someone who doesn't want a baby?
If anyone could give us any help or advise we'd be very grateful. This is not the kind of stress we need after such a rough few months!
Thanks in advance,
Natasha
I'm very surprised by this! I also had to have a D&C for the same reasons at the beginning of 2013, and my basic insurance paid 100% of the bill!

I think you should ask your doc to write a letter to the medical advisor of your insurance.
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Old 13.05.2014, 13:20
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Re: Please help, advice needed on insurance coverage on pregnancy

Can the consultant not write to the insurance company and explain that this wasn't a elective decision on your part, but as a result of a pregnancy going wrong and threatening your life if you didn't have the op? To me that turns it into an "illness" for which the only cure was a d&c.

Really sad news and you certainly don't want more stress after what you've been through. Hope the insurance company shows some compassion and sorts this all out for you properly.
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Old 13.05.2014, 15:50
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Re: Please help, advice needed on insurance coverage on pregnancy

Sorry to hear you had to have the operation and that the insurance is being tough. I agree a letter from your doctor should help get it sorted. If you can get it reclassified as a procedure related to an illness, keep in mind that you may still be responsible for some of the cost, up to your franchise/deductible. Good luck.
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Old 13.05.2014, 16:23
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Re: Please help, advice needed on insurance coverage on pregnancy

I am wondering if the hospital/doctor coded the procedure in wrong with the health insurance.

Either way, I am sure your doctor would be able to advocate for you and point out that it was a medically necessary procdedure.

And yes, the fact that there was no heartbeat makes it a very different procedure. It is definitely not an 'abortion' as that word means you have stopped the pregnancy, but in your case, it was a loss of pregnancy that would have ended sooner or later with miscarriage, but the purpose of the d&c is to try to avoid further complications such as bleeding or infection.

And if it helps any, a friend of mine was in a similar situation but advised to wait for the spontaneous miscarriage, and ended up haemorrhaging and being extremely ill for months afterwards.... Plus post traumatic stress from the actual experience of the emergency illness... So it is definitely justified to have the d&c...
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Old 13.05.2014, 16:31
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Re: Please help, advice needed on insurance coverage on pregnancy

Firstly,

I'm sorry for your loss, but as others have said, I would get your GP involved in this.

I can understand from a policy perspective that perhaps you weren't covered.... but it is completely incorrect for them to say that this was "elective surgery".

If the doctor instructs you to have the opperation, then you may not be covered under your Sanitas cover for illness, but you should be covered under an accident policy at the very least.

Generally the doctors instruction is all they will need to confirm that this was a life threatening opperation and I doubt there will be further questions asked.

Good luck with everything.

Seriously.... talk to your GP.
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Old 13.05.2014, 16:44
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Re: Please help, advice needed on insurance coverage on pregnancy

I have had 2 miscarriages and everything related to them was paid out of pocket now I didn't have a D&C but meds, consults, scans etc were not covered. And they still continue to call them "abortions" which to me drives me nuts because in my mind an abortion is an elective procedure. It's like the word miscarriage isn't in their medical vocabulary.

I'm sorry for your loss and would also ask your doc to write a letter.
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Old 13.05.2014, 16:56
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Re: Please help, advice needed on insurance coverage on pregnancy

They should definitely cover the treatment in this instance. What is however possible is that the deductible and franchise apply. Costs incurred after the 13th week are definitely not subjected to any deductible or franchise.

Under paragraph 8 on this website you can find the issue: http://www.bag.admin.ch/themen/krank...x.html?lang=en
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Old 13.05.2014, 16:57
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Re: Please help, advice needed on insurance coverage on pregnancy

Hmm. We (my wife, obviously) had a D&C due to a missed-miscarriage in week 11. We were informed that this is not covered by normal pregnancy insurance, but it should be covered by normal health insurance (minus the excess).
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Old 13.05.2014, 17:02
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Re: Please help, advice needed on insurance coverage on pregnancy

Yes that is exactly what should be the case. So the question is to the OP - is your franchise that high? Then it is possible that the d&c is not covered. I am very sorry this happened to you.
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Old 14.05.2014, 12:16
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Re: Please help, advice needed on insurance coverage on pregnancy

If the bill says "LAMAL" or "KVG" on it, it is 100% covered... But 'covered' doesn't mean that you get all your money back.

- if anything happens before 13th week, it's not 'pregnancy-related', but just 'illness', so it is covered, but you have to pay the deductable / franchise you have chosen, and maybe 10% after that, as per usual Swiss basic health insurance rules..

- if anything happens after 13 week, it's 'pregnancy' and it's covered without any deductable.


I suspect you have a high dedutable? E.g, 2000 or 2500 CHF in the year, so they are basically saying, we are covering it, but still no refund as it's below 2500 CHF or whatever you chose?

PS: The new law from apr 14 (doesn't apply to your case anyway) but says that any illness after week 13 will now be reimbursed 100% as pregnancy, before it was that only certain things counted, the rest was 'illness' and fall under normal franchise.
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Old 20.01.2015, 12:19
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Re: Please help, advice needed on insurance coverage on pregnancy

Going through the similar situation myself.
I am on basic insurance with 2500chf deductible.
I had my 1st ob-gyn visit at 8w5d. Doctor found out that the baby stopped growing at 6/7 wks and that there is no heartbeat. She asked me to come back a few days later to re-check in case my days were off.. No change at 2nd checkup so she proposed a pill or d&c. I have opted out for a pill ( she ruled out waiting as it could take weeks and cause complications). Unfortunately the pill didnt work for me so i am now scheduled for d&c. I have already received bills for my 3 visits ( they dont waste here with bills do they?) and they are all issued under maladie. This is somewhat bizarre to me as i thought that all pre-natal checks are "free of charge/ free of franchise= automatically covered by insurance".. Well guess, not if there are complications.. I suspect i will have to cover d&c as well even if its not by my choice.. Has someone been in similar situation? What was your billing outcome? Did you managed to get first ob-gyn visits and d&c covered by insurer directly and not pay out of your pocket/franchise? TIA
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