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Old 22.06.2018, 18:51
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Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

As I got to know, my insurance provider (swisscare) would not cover any treatment of sinusitis as they consider it a pre-condition. (I had the same problem last year and they paid all the treatment back then, but nevermind.)
Now as the problem from the last year reocurred, there is a big chance I may need FESS surgery of sinuses as the doctor warned me a year ago. If they do not want to cover anything concerning sinusitis then I think they will not cover the surgery for sure. Would this be covered by any normal (non-swiss-care) insurance company or not? I am now considering taking a vacation and travelling abroad to get cheaper treatment there, because my health problem is unbearable, but as a PhD student I could not afford the treatment here. Does anybody have a similar experience? What did you do?
Thanks and have a nice day.
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Old 22.06.2018, 19:13
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

I'm sorry, I don't understand.
Last year you had sinusitis, and your medical insurer paid for all the treatment.
If they paid for everything last year, why would they not pay for the treatment this year?

This year, your condition has recurred, and is now even worse, such that it will probably require surgery.

Why, then, would your medical insurance now regard a more serious development of the condition as a "pre-condition"? Who told you this? Based on which rules/laws?
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Old 22.06.2018, 19:22
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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Would this be covered by any normal (non-swiss-care) insurance company or not?
No.
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Old 22.06.2018, 19:31
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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I'm sorry, I don't understand.
Last year you had sinusitis, and your medical insurer paid for all the treatment.
If they paid for everything last year, why would they not pay for the treatment this year?

This year, your condition has recurred, and is now even worse, such that it will probably require surgery.

Why, then, would your medical insurance now regard a more serious development of the condition as a "pre-condition"? Who told you this? Based on which rules/laws?
Yes, they paid everything last year (prescription medication + 2x doctor visit), but they consider it a pre-condition now. I am still insured at the same company (swiss-care) for 2 years now. I asked the company by e-mail and they wrote me it is considered a pre-condition now. It does not make any sense to me either.
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Old 22.06.2018, 19:43
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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As I got to know, my insurance provider (swisscare) would not cover any treatment of sinusitis as they consider it a pre-condition. (I had the same problem last year and they paid all the treatment back then, but nevermind.)
Now as the problem from the last year reocurred, there is a big chance I may need FESS surgery of sinuses as the doctor warned me a year ago. If they do not want to cover anything concerning sinusitis then I think they will not cover the surgery for sure. Would this be covered by any normal (non-swiss-care) insurance company or not? I am now considering taking a vacation and travelling abroad to get cheaper treatment there, because my health problem is unbearable, but as a PhD student I could not afford the treatment here. Does anybody have a similar experience? What did you do?
Thanks and have a nice day.
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No.
That's not what Klinik Hirslanden says. (German). It depends what exactly your problem is, whether the doctors think you need surgery .....

I know nothing about Swisscare though, which doesn't seem to be a Swiss health insurance but some travel - student-thing?
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Old 22.06.2018, 19:53
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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That's not what Klinik Hirslanden says. (German). It depends what exactly your problem is, whether the doctors think you need surgery .....

I know nothing about Swisscare though, which doesn't seem to be a Swiss health insurance but some travel - student-thing?
I might be wrong, but I thought she wanted to get another insurance here or abroad for what without doubt would be considered a pre-condition.
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Old 22.06.2018, 20:05
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I might be wrong, but I thought she wanted to get another insurance here or abroad for what without doubt would be considered a pre-condition.
I was asking if a different insurance provider would have paid the surgery normally. (It is clear that if I change the insurance now, the new company would consider it as a pre-condition, because it ocurred already before, when I was insured at swiss-care.) So I think if swiss-care decides not to pay for it then I have to pay for it myself. Which means I have to make a trip somewhere abroad where medical care is affordable.

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That's not what Klinik Hirslanden says. (German). It depends what exactly your problem is, whether the doctors think you need surgery .....

I know nothing about Swisscare though, which doesn't seem to be a Swiss health insurance but some travel - student-thing?
Many PhD students have swiss-care as they are not earning a lot and they are only temporarily (3-4 years) in Switzerland. In theory, swiss-care should cover what the obligatory health insurance providers cover in Switzerland. In theory, I guess.

Last edited by 3Wishes; 22.06.2018 at 21:41. Reason: merging consecutive replies
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Old 22.06.2018, 20:12
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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I was asking if a different insurance provider would have paid the surgery normally. (It is clear that if I change the insurance now, the new company would consider it as a pre-condition, because it ocurred already before, when I was insured at swiss-care.) So I think if swiss-care decides not to pay for it then I have to pay for it myself. Which means I have to make a trip somewhere abroad where medical care is affordable.
It doesn't matter AT ALL whether something is a pre-condition or not in Swiss basic health care insurance.

The only place these things matter is the private, additional insurance (Zusatzversicherung).

And as those sinus-things - according to the link I posted - can also be caused by accident, depending on which type it is, it's payed by the accident insurance. Your's sounds like illness.
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Old 22.06.2018, 20:19
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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I was asking if a different insurance provider would have paid the surgery normally. (It is clear that if I change the insurance now, the new company would consider it as a pre-condition, because it ocurred already before, when I was insured at swiss-care.) So I think if swiss-care decides not to pay for it then I have to pay for it myself. Which means I have to make a trip somewhere abroad where medical care is affordable.
My mistake.

What you can do however is:

Ask Swisscare to send you a written response containing the justification for a decision that has been taken and information on your legal rights. After this you have 30 days to formally appeal this if you do not agree with their decision, their response has to contain the reasons why they will not pay and has to contain info on what your rights are, if this formal appeal does not give the righteous outcome you can lodge a written complaint against the Swisscare’s response to your appeal with the Cantonal Insurance Court within 30 days (also possible if their response is incomplete), If even this does not give the correct result you can go to the federal court for a final verdict.

How far you want to go is up to you, the last step bears a financial risk since losing is always possible if even the Insurance court already disagreed.
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Old 22.06.2018, 20:23
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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It doesn't matter AT ALL whether something is a pre-condition or not in Swiss basic health care insurance.

The only place these things matter is the private, additional insurance (Zusatzversicherung).

And as those sinus-things - according to the link I posted - can also be caused by accident, depending on which type it is, it's payed by the accident insurance. Your's sounds like illness.
Swisscare is not like your average Swiss basic health care insurance.
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Old 22.06.2018, 20:41
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It doesn't matter AT ALL whether something is a pre-condition or not in Swiss basic health care insurance.

The only place these things matter is the private, additional insurance (Zusatzversicherung).

And as those sinus-things - according to the link I posted - can also be caused by accident, depending on which type it is, it's payed by the accident insurance. Your's sounds like illness.
Thanks a lot for the link.
It was only acute last year, but it seems to become chronic this year. It is not caused by an accident, but rather reocurring infection which then gets into chronic stage, I think. I have no clue how swiss insurance system treats reocurring infections. Or how do insurance companies treat it. One organ can get different infection multiple times in life, but if having it once meant that if it happens next time, it is pre-condition which will not be reimbursed, it would be weird. For example, if one would have some kind of infection in childhood, would it mean that when coming to another insurance provider he would not be reimbursed for another infection of the same organ anymore? Say pneumonia or so when talking about lungs or sinusitis when talking about sinuses? One cannot even say if it was the same bacteria unless this was tested back then and now and compared...

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My mistake.

What you can do however is:

Ask Swisscare to send you a written response containing the justification for a decision that has been taken and information on your legal rights. After this you have 30 days to formally appeal this if you do not agree with their decision, their response has to contain the reasons why they will not pay and has to contain info on what your rights are, if this formal appeal does not give the righteous outcome you can lodge a written complaint against the Swisscare’s response to your appeal with the Cantonal Insurance Court within 30 days (also possible if their response is incomplete), If even this does not give the correct result you can go to the federal court for a final verdict.

How far you want to go is up to you, the last step bears a financial risk since losing is always possible if even the Insurance court already disagreed.
Thank you, but I donīt want to go to court, I cannot afford it (financially nor timewise). But I will ask them for more explanation. How they come to this being a pre-condition and why it shouldnīt be paid then... Maybe they try this more often, not to pay what they should...

Quote:
Swisscare is not like your average Swiss basic health care insurance.
I know it is not completely the same, but it is allowed (as an extemption after applying for it) for students to have swiss-care insurance if swiss-care covers what is under the obligatory swiss insurance scheme. But I donīt know if anyone can force them to really do that if they are not a normal swiss insurance company. If I could choose again, I would have paid a bit more and took some normal insurance company, but too late...

Last edited by 3Wishes; 22.06.2018 at 21:43. Reason: merging consecutive replies; please use multi-quote (button to the right of quote)
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Old 22.06.2018, 20:58
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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I know it is not completely the same, but it is allowed (as an extemption after applying for it) for students to have swiss-care insurance if swiss-care covers what is under the obligatory swiss insurance scheme. But I donīt know if anyone can force them to really do that if they are not a normal swiss insurance company. If I could choose again, I would have paid a bit more and took some normal insurance company, but too late...
Well, if you found a way to circumvent the normal health-insurance-situation here then ...... you have to live with the implications.

Health insurances can be changed at the end of every year. Now I don't know HOW special this Swisscare is but I guess it's not a life-contract?

So you could get a regular health-insurance for January 1st (don't forget to study the cancellation terms of Swisscare!!! Don't miss the date of notice.) and have it done next year.
I repeat: If the doctor's agree with you that there is a need for this.
I also repeat: Preconditions are no subject for basic health insurances here.

All the best.
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Old 22.06.2018, 21:04
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

Here's my advice.

1. Make absolutely sure that this operation is the right and necessary treatment. If you and/or your doctors are only a the stage of speculation, you might consider getting a second opinion.

2. Find out whether your current insurance would pay for you to see another doctor about this and/or the cost of seeing one if you were to pay yourself.

3. If either doctor 1 or doctor 2 or both are certain that you need the operation, ask them to give you all the details, including not only the diagnoses, but also the reasons these diagnoses result in a need for an operation and also the prognosis if the operation were not done.

4. Show the doctors what you have been given by the medical insurance refusing cover. Ask the doctors to ask to speak to the "Vertrauensarzt" (literally "trusted doctor") of the insurance company who, unlike the administrative staff, understands the medical consequences, and unlike your doctor and you, understands the insurance side. This can sometimes be the key to getting the medical insurance to cover the costs.

5. If that doesn't work, there's always Edwin's suggestion of asking the medical insurance to state, in writing, on what legal basis they intend to refuse to cover the costs. Doing this takes the matter out of the hands of an administrative staff member (who may not know what they are doing) to the insurance's legal department, where someone will have to find out on what basis they justify the refusal.

6. Curley's suggestion of changing to a basic, obligatory Swiss medical insurance is good. She is right that this insurance ("Grundversicherung") knows no such thing as excluding any condition which pre-existed the start of the insurance. If you can get the timing right of when to give notice from swisscare and when to start the new insurance, and if waiting doesn't put you in medical jeopardy, that might be the route to go. However, since the new premium is likely to cost more (I'm guessing), it'd be wise to be completely sure that you need the operation, and that swisscare will really not pay, before you leave them.
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Old 22.06.2018, 21:22
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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Thank you, but I donīt want to go to court, I cannot afford it (financially nor timewise). But I will ask them for more explanation. How they come to this being a pre-condition and why it shouldnīt be paid then... Maybe they try this more often, not to pay what they should...
The Cantonal Insurance Court is free of charge (but can only be done when already appealed formally towards your insurance), unless you go to the federal court the whole thing would only cost you some time and stamps.

And I cannot look in your agenda, but avoiding having to travel abroad to pay yourself for an operation if money and time seem to be an issue already is something worth putting some effort in imho.
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Old 22.06.2018, 21:25
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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6. Curley's suggestion of changing to a basic, obligatory Swiss medical insurance is good. She is right that this insurance ("Grundversicherung") knows no such thing as excluding any condition which pre-existed the start of the insurance. If you can get the timing right of when to give notice from swisscare and when to start the new insurance, and if waiting doesn't put you in medical jeopardy, that might be the route to go. However, since the new premium is likely to cost more (I'm guessing), it'd be wise to be completely sure that you need the operation, and that swisscare will really not pay, before you leave them.
I agree, but OP should make a calculation when switching, it is to be expected that the monthly payment goes up, and given the pre-condition the own risk will be set at 2.500,- and there's the 10% of al other expenses up to a max of 700,-

And I honestly have no clue what the operation would cost elsewhere, perhaps it is even cheaper to just pay up instead of Switching and have it here.
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Old 22.06.2018, 21:32
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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I agree, but OP should make a calculation when switching, it is to be expected that the monthly payment goes up, and given the pre-condition the own risk will be set at 2.500,- and there's the 10% of al other expenses up to a max of 700,-
By "own risk", you mean the "franchise"? This can be set as low as Fr. 300 per annum, plus then the 10% up to a max of Fr. 700 per annum.

But Edwin, are you sure? I have never heard of a pre-condition ever being relevant to determine the level of the franchise. As far as I have understood it till now, the level of the franchise is only a question of the insured person's personal choice, (the higher the annual franchise, the lower the Monthly premium, the lower the annual franchise, the higher the monthly premium) and never a requirement set by the insurance company.
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Old 22.06.2018, 21:54
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

You can only be exempt from regular insurance if you meet certain conditions.

Roughly: (1) you have insurance in another (EU?) country under their social security system
or
(2) the student plan you take (e.g. Swisscare) meets the requirements of the Swiss Health insurance act.

I just looked at Swisscare website, and they confirm the policy meets the KVG / LaMal requirements. So there is no justification for Swisscare to refuse coverage if the Swiss doctor is recommending a "normal" course of treatment. (i.e. not experiemental or similar)

Of course, if you have an insurance for private room, then this is an extra thing, and the insurance company could refuse to cover pre-existings for that cover. But still they must pay at the "general shared room" level.

I agree with doropfiz's suggestion point 4 - get your doctor to speak with the insurance company.

details here of the rules for exemptions:
http://www.jgk.be.ch/jgk/de/index/pr...20englisch.pdf
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Old 22.06.2018, 23:35
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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You can only be exempt from regular insurance if you meet certain conditions.

Roughly: (1) you have insurance in another (EU?) country under their social security system
or
(2) the student plan you take (e.g. Swisscare) meets the requirements of the Swiss Health insurance act.

I just looked at Swisscare website, and they confirm the policy meets the KVG / LaMal requirements. So there is no justification for Swisscare to refuse coverage if the Swiss doctor is recommending a "normal" course of treatment. (i.e. not experiemental or similar)

Of course, if you have an insurance for private room, then this is an extra thing, and the insurance company could refuse to cover pre-existings for that cover. But still they must pay at the "general shared room" level.

I agree with doropfiz's suggestion point 4 - get your doctor to speak with the insurance company.

details here of the rules for exemptions:
http://www.jgk.be.ch/jgk/de/index/pr...20englisch.pdf
yes, thatīs how it should be.
(I used to have insurance in EU country which I had to cancel and make swiss one instead - unfortunately, one is not allowed to have 2 basic health insurances in two countries one being EU and one Switzerland as I got to know. Otherwise I would happily kept my original too, but it was not (legaly) possible. Here in Switzerland I chose out of all options swiss-care as other students recommended it to me. You are right, they should fulfil this LaMal thing, it is stated in the contract too as far as I know.)

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The Cantonal Insurance Court is free of charge (but can only be done when already appealed formally towards your insurance), unless you go to the federal court the whole thing would only cost you some time and stamps.

And I cannot look in your agenda, but avoiding having to travel abroad to pay yourself for an operation if money and time seem to be an issue already is something worth putting some effort in imho.
Good to know, thank you, I hope I will not need it!

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Here's my advice.

1. Make absolutely sure that this operation is the right and necessary treatment. If you and/or your doctors are only a the stage of speculation, you might consider getting a second opinion.

2. Find out whether your current insurance would pay for you to see another doctor about this and/or the cost of seeing one if you were to pay yourself.

3. If either doctor 1 or doctor 2 or both are certain that you need the operation, ask them to give you all the details, including not only the diagnoses, but also the reasons these diagnoses result in a need for an operation and also the prognosis if the operation were not done.

4. Show the doctors what you have been given by the medical insurance refusing cover. Ask the doctors to ask to speak to the "Vertrauensarzt" (literally "trusted doctor") of the insurance company who, unlike the administrative staff, understands the medical consequences, and unlike your doctor and you, understands the insurance side. This can sometimes be the key to getting the medical insurance to cover the costs.

5. If that doesn't work, there's always Edwin's suggestion of asking the medical insurance to state, in writing, on what legal basis they intend to refuse to cover the costs. Doing this takes the matter out of the hands of an administrative staff member (who may not know what they are doing) to the insurance's legal department, where someone will have to find out on what basis they justify the refusal.

6. Curley's suggestion of changing to a basic, obligatory Swiss medical insurance is good. She is right that this insurance ("Grundversicherung") knows no such thing as excluding any condition which pre-existed the start of the insurance. If you can get the timing right of when to give notice from swisscare and when to start the new insurance, and if waiting doesn't put you in medical jeopardy, that might be the route to go. However, since the new premium is likely to cost more (I'm guessing), it'd be wise to be completely sure that you need the operation, and that swisscare will really not pay, before you leave them.
Thanks. I am surely not going for the surgery if it is not 100% needed. If it is going to happen I will have a long discussion with doctor/s... (The thing at a moment was that the insurance company stated that they wouldnt pay anything without even knowing there might be a surgery - which is probably the most expensive treatment possible.) points 4 and 5 seem like a good idea, I did not know insurance company has such a person.

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Well, if you found a way to circumvent the normal health-insurance-situation here then ...... you have to live with the implications.

Health insurances can be changed at the end of every year. Now I don't know HOW special this Swisscare is but I guess it's not a life-contract?

So you could get a regular health-insurance for January 1st (don't forget to study the cancellation terms of Swisscare!!! Don't miss the date of notice.) and have it done next year.
I repeat: If the doctor's agree with you that there is a need for this.
I also repeat: Preconditions are no subject for basic health insurances here.

All the best.
I am seriously considering it, but I donīt know if the new insurance company would then pay for a surgery or not, because I already have this problem now, prior to getting insured at their company. A real pre-condition, if I understand this term correctly.


Anyway, thanks a lot, people! Your advices were useful I will talk with the doctor to make sure what needs to be done. Probably they need to talk to each other - the insurance company and the doctor. I will ask the insurance company for the reason and official letter of refusing to pay and see what happens next. I may end up changing the insurance company too, but only if the new provider covers pre-conditions/repeated conditions. Hopefuly it all somehow works out...
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Old 22.06.2018, 23:45
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

I cannot presume to understand the special insurance that you have. Even so, as Heckenhocker set out, that special insurance is valid only if it is at least equivalent to the Swiss basic, obligatory medical insurance. And you say that you have it in writing that it is equivalent. Good.

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...I donīt know if the new insurance company would then pay for a surgery or not, because I already have this problem now, prior to getting insured at their company. A real pre-condition, if I understand this term correctly.
I think you are still misunderstanding something. You really, really need to understand this point, as Curley has already set out.

In Switzerland, the basic, obligatory medical insurance (called "Grundversicherung" in German) does not, ever, at all, in any way, exclude a person from insurance because of a pre-existing condition. They cannot and will not.

Exclusion on the basis of pre-existing conditions is not a concept of the obligatory medical insurance. Such exclusion is only permitted for supplementary (= extra, going beyond the obligatory) insurance.

Therefore, if the treatment you need would be covered by the basic, obligatory insurance, then it cannot be excluded.
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Old 22.06.2018, 23:55
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Re: Sinuses surgery FESS - insurance probably not cover - travel for surgery abroad?

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By "own risk", you mean the "franchise"? This can be set as low as Fr. 300 per annum, plus then the 10% up to a max of Fr. 700 per annum.

But Edwin, are you sure? I have never heard of a pre-condition ever being relevant to determine the level of the franchise. As far as I have understood it till now, the level of the franchise is only a question of the insured person's personal choice, (the higher the annual franchise, the lower the Monthly premium, the lower the annual franchise, the higher the monthly premium) and never a requirement set by the insurance company.
Yes I ment franchise.

My wife has an existing condition and thus would have loved to lower the franchise for this and at least next year, unfortunately this was not possible at her own insurance, and we tried two other companies but both insisted on the maximum franchise due to the existing condition.
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