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Old 01.05.2015, 12:32
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Swisscare - Does not reimburse payment for a cancer treatment.

In need of urgent help as Swisscare sent a note indicating that:
- the Swissmedic of permission does not cover Monotherapy of Mabthera.

Monotherapy of mabthera is cancer treatment recommended by our doctors in Unispital, ZH for lymphoma (cancer).

Does anyone know if there is a federal list of treatments covered within Basic insurance? I do not understand why the Basic insurance would not reimburse payment for treatment of cancer.

The insurance plan with Swisscare is the FSS plan.

The treatments were done from May last year, which we have paid for personally (as Swisscare only reimburses later). However, they never responded for months and now after much chasing, we have received a response indicating they will not pay for the treatment, due to reasons mentioned above..

Treatment costs until now are almost 30,000 CHF, hence, very disturbing to learn about this now and do not know why we would be paying for insurance coverage if they do not even cover such treatment..(far more serious than many other illnesses..)

I would appreciate any information you can provide to help us understand our rights to claim for this treatment:
- Is there a list of treatments (medical names) covered in Switzerland by law?
- Has anyone been in this situation and can you pls. share your experience/advise?

Thanks in advance
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Old 01.05.2015, 12:48
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Re: Swisscare - Does not reimburse payment for a cancer treatment.

The basic swiss health insurance is legislated by the LAMal law

https://www.admin.ch/opc/fr/classifi...tion/19940073/

There is a list of medications covered under basic insurance but it's quite impenetrable to a layman

http://www.bag.admin.ch/themen/krank...x.html?lang=fr

What I would suggest to do is to contact your local OFS (office de la sante publique in the french region) and discuss with them. They would have the leverage to ask an insurance to cover something if there is an underlying legal requirement

Whether this particular treatment is covered or not I do not know.
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Old 01.05.2015, 13:02
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Re: Swisscare - Does not reimburse payment for a cancer treatment.

Your doctor should know if a treatment is covered by basic insurance, if it isn't they should inform you before going ahead with it.

All basic insurance has to cover the same things. So firstly find out if it should be covered, if it should take it up with the insurer. If it isn't covered then take it up with the doctor as they didn't inform you that it wasn't covered.
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Old 01.05.2015, 13:29
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Re: Swisscare - Does not reimburse payment for a cancer treatment.

Thank you Dandi & Island_Monkey.

@Island_Monkey: When the treatment was recommended by the doctor at Unispital Zurich, we asked if it would be covered by insurance and were informed that it would be covered. (Which is why we are confused with the response from the insurance company..)
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Old 01.05.2015, 13:31
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Re: Swisscare - Does not reimburse payment for a cancer treatment.

Surprising:

Frequently asked questions, saying "whatever is on the Spezialitštenliste and has been prescribed within the limits as allowed":

http://www.bag.admin.ch/themen/krank..._JjKbNoKSn6A--

... and the entry on the Spezialitštenliste:

http://www.spezialitaetenliste.ch/ShowPreparations.aspx - search for MabThera.

So in general this *specific* medication
- Mabthera Inf Konz 100 mg/10ml (54378017)
- Mabthera Inf Konz 500 mg/50ml (54378025)
is covered under the KVG, within the limits defined for the medication.

And apparently (https://www.swissmedic.ch/arzneimitt..._JjKbNoKSn6A--) these are the two only products that may be used in Switzerland, too.

Ask your health insurance what the problem is.
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Old 01.05.2015, 14:12
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Re: Swisscare - Does not reimburse payment for a cancer treatment.

What a nightmare.. you should not be in this position. The doc should have guided you through this... (I've been through something similar..so this isn't theory)

The question - for the doctor - is simply..

Does Swissmedic approve that drug/treatment regime for that disease ? If no.. then the doc went 'off label' and is responsible (highly unlikely)

If yes then.. did the doc write to the insurance company making the case for treatment ? If yes then.. where's the written response ? If not.. why not ? ('It's usually covered by basic insurance' isn't an acceptable answer... for cases like this only the doc can make the medical argument as to why the treatment is necessary and why the relatively high costs are unavoidable. )
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