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Old 26.05.2018, 12:44
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Assura Maternity Claims

Hi,

My wife is pregnant and we have Assura as our insurance.

The below communication was sent to my wife when we asked about claims we have made relating to the maternity.

They have said that we need to get our Gynacologist to send them a "Maternity Announcement" which we have now done. The Gynacologist said that usually the reclaim receipts are taken as proof that is a maternity but said Assura can often be difficult.

Also they have said that they have received no claims from us. Stupidly I sent the claims by non-registered mail as I trusted the insurance company would be trustworthy. I have requested a second copy of all the Rückforderungsbeleg for the bills I have paid and will send them again by registered mail!

The question I have is in relation to the articles 25, 25a, 29 and 64 referred to in the email below. I have looked these up and didn't think there was any restriction on what could be claimed?


Quote:
Madame,

Votre courriel du 17 mai 2018 nous est bien parvenu et a retenu toute notre attention.

A ce propos, nous vous informons qu'à ce jour aucune facture n'est visible dans votre dossier et que nous n'avons aucune information concernant votre grossesse.

Afin de que nous puissions créer votre dossier maternité, nous vous prions de bien vouloir faire diligence auprès de votre gynécologue afin qu'il nous fasse parvenir le formulaire "annonce de maternité".

Nous profitons de cette occasion pour vous présenter nos meilleurs voeux.

C'est avec plaisir que nous vous remettons en annexe le document "Prestations en cas de maternité". Vous y trouverez des informations importantes sur les conditions de prise en charge des prestations dans le cadre de votre maternité. Il vous est recommandé de le lire attentivement.



A ce propos, nous vous confirmons qu?avant la 13ème semaine de grossesse, seules les prestations spécifiques citées aux articles 29 de la Loi fédérale sur l'assurance-maladie (LAMal) et 13 à 16 de l?Ordonnance sur les prestations de l?assurance obligatoire des soins (OPAS), sont exemptées de la participation aux coûts.

De plus, les prestations mentionnées expressément aux articles 25 et 25a de la Loi fédérale sur l?assurance-maladie (LAMal) fournies dès la 13ème semaine de grossesse et jusqu?au 56ème jour après l?accouchement, à minuit, sont exemptées de la participation aux coûts au sens de l?article 64, al. 7 de la LAMal.
Par contre, les coûts des mesures de prévention, des prestations en cas d?infirmité congénitale, d?accident, d?interruption de grossesse non punissable et les soins dentaires restent soumis à la franchise et à la quote-part.

Nous restons à votre disposition pour tout renseignement complémentaire et vous adressons, Madame, nos meilleures salutations.

Assura-Basis SA
Département des prestations
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Old 26.05.2018, 12:55
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Re: Assura Maternity Claims

Here the LAMal (not available in English, linked to French version, language can be changed on to right corner) https://www.admin.ch/opc/fr/classifi...073/index.html

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I have looked these up and didn't think there was any restriction on what could be claimed?
Sure there is. There are things during maternity which are paid w/o deductible/franchise. Some other things, if covered by basic insurance, are subject to detuctible/franchise, and finally some things which are not covered even not by private insurance. For example determine the gender of the child by other means then ultrasound imaging, a midwife reachable in 5 minutes 24/7 anywhere, first class train tickets because there is more room, an ultrasound each and every day unless there is very good medical reason for that.
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Old 26.05.2018, 13:05
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Re: Assura Maternity Claims

Thank you for the information. Yes the gender tests are logical and fair in m opinion.

I guess what I'm really trying to ask is about the reference to the 13th week of pregnancy only certain benefits are covered.
We had an 8th and 12th week scan. A range of blood tests were done at 8 weeks and at both appointments there was some medication prescribed by the doctor. Are these generally all covered?

Also this post was not just meant to ask these questions but also to inform other forum users about how Assura has dealt with us. I found the fact that they said they have not received any claims from us really infuriating.
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Old 26.05.2018, 13:19
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Re: Assura Maternity Claims

On Assura: It is a Tiers Garant insurance (bills go to patient which has to pay and then reclaim from insurance), That's is enough to avoid it.

On Prgancy:

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I guess what I'm really trying to ask is about the reference to the 13th week of pregnancy only certain benefits are covered.
Before the 13 week a complication/miscarriage would be considered an illness and deductible/franchise applies. After that it is deductible and franchise free. Hope you and others will never be in this situation. Neither before nor after 13th week.

See also ch.ch what is covered and when deductible/franchise applies (in Englisch).
https://www.ch.ch/en/pregnancy-health-insurance-covers/
and form the Office fédéral de la santé publique (unfortunatly no English text)
https://www.bag.admin.ch/bag/fr/home...terschaft.html

specialy the "Foire aux questions concernant les prestations"

Quote:
Quels examens de contrôles peuvent être effectués durant la grossesse et après l’accouchement ?

Lors d’une grossesse normale sept examens de contrôles sont remboursés. La première consultation comprend l’anamnèse, l’examen gynécologique et clinique généraux et les conseils, l’examen des veines et la recherche ’œdèmes des jambes, ainsi que la prescription des analyses de laboratoire nécessaires conformément à la liste des analyses. Les consultations ultérieures comprennent le contrôle du poids, de la tension artérielle, de la hauteur de l’utérus, l’examen urinaire et l’auscultation des bruits cardiaques fœtaux, ainsi que la prescription des analyses de laboratoire nécessaires conformément à la liste des analyses
you may also use the help of www.deepl.com or translate.google.com

PS: Happy congratulations and all the best, for mother, child, and father as well.
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Old 27.05.2018, 17:50
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Re: Assura Maternity Claims

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On Assura: It is a Tiers Garant insurance (bills go to patient which has to pay and then reclaim from insurance), That's is enough to avoid it.
For us thankfully we are able to pay it and claim it back later. It is just annoying having to go through these issue but for others not able to afford to wait, I can imagine it is very stressful.
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