Go Back   English Forum Switzerland > Help & tips > Insurance  
Reply
 
Thread Tools Display Modes
  #1  
Old 16.11.2018, 15:46
Newbie
 
Join Date: Nov 2018
Location: Basel
Posts: 8
Groaned at 0 Times in 0 Posts
Thanked 1 Time in 1 Post
MrJolly has no particular reputation at present
Insurer refusing to pay for drugs

I suffered a nasty ESBL infection only treatable by (expensive) carbapenem antibiotics administered through an IV. I received around CHF 10k in bills from my doctor for the treatment which I duly paid almost two months ago but received no reimbursement from my insurer. When I rang to ask why today, my insurer is saying they wonít pay because 1. the drug is not on their list for the infection I suffered from, and 2. the doctor didnít request their approval prior to prescribing the treatment.

I explained to the insurer that the lab tests clearly show the only drugs that would work on the infection was the one prescribed, and that I am left more than CHF 10k out of pocket through no fault of my own whilst theyíve received their premium payments in full and the doctor has also been paid in full. Their response was that I should complain to my doctor!

It seem seems my doctor did send a detailed explanation but the insurer has dismissed it.

I have to say I am very angry at the way this case has been handled, and whilst I will raise this with my doctor I would be grateful for any other advice anyone can give on what I can do to get reimbursed.
Reply With Quote
  #2  
Old 16.11.2018, 16:38
slammer's Avatar
Forum Legend
 
Join Date: Jul 2009
Location: Lummerland
Posts: 4,627
Groaned at 116 Times in 81 Posts
Thanked 7,785 Times in 2,901 Posts
slammer has a reputation beyond reputeslammer has a reputation beyond reputeslammer has a reputation beyond reputeslammer has a reputation beyond reputeslammer has a reputation beyond reputeslammer has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Things like that make you want to Molotov your insurers office.
Reply With Quote
  #3  
Old 16.11.2018, 16:42
Forum Veteran
 
Join Date: Oct 2014
Location: Nyon
Posts: 1,352
Groaned at 52 Times in 34 Posts
Thanked 1,230 Times in 624 Posts
bowlie has a reputation beyond reputebowlie has a reputation beyond reputebowlie has a reputation beyond reputebowlie has a reputation beyond repute
Re: Insurer refusing to pay for drugs

I recommend you ask your Dr. to appeal their decision.
Reply With Quote
The following 2 users would like to thank bowlie for this useful post:
  #4  
Old 16.11.2018, 17:31
Newbie
 
Join Date: Nov 2018
Location: Basel
Posts: 8
Groaned at 0 Times in 0 Posts
Thanked 1 Time in 1 Post
MrJolly has no particular reputation at present
Re: Insurer refusing to pay for drugs

Quote:
View Post
I recommend you ask your Dr. to appeal their decision.

I will do that, but is that the only route (e.g. is there such a thing as an ombudsman responsible for health insurers) or is it just tough?
Reply With Quote
  #5  
Old 16.11.2018, 17:44
fatmanfilms's Avatar
Forum Legend
 
Join Date: Apr 2010
Location: Verbier
Posts: 17,565
Groaned at 279 Times in 228 Posts
Thanked 14,901 Times in 8,296 Posts
fatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Quote:
View Post
I will do that, but is that the only route (e.g. is there such a thing as an ombudsman responsible for health insurers) or is it just tough?
There is an official list of drugs all insurance companies have to pay for, if it's not on the list I don't think there is much you can do.
Reply With Quote
The following 6 users would like to thank fatmanfilms for this useful post:
  #6  
Old 16.11.2018, 17:51
Newbie
 
Join Date: Nov 2018
Location: Basel
Posts: 8
Groaned at 0 Times in 0 Posts
Thanked 1 Time in 1 Post
MrJolly has no particular reputation at present
Re: Insurer refusing to pay for drugs

Quote:
View Post
There is an official list of drugs all insurance companies have to pay for, if it's not on the list I don't think there is much you can do.
Thatís pretty much what they told me. However, as I pointed out to them the doctor prescribed the only drug that the bacteria showed sensitivity to in the lab test. Crazy rules.
Reply With Quote
  #7  
Old 16.11.2018, 17:58
Forum Legend
 
Join Date: Sep 2006
Location: SZ
Posts: 9,457
Groaned at 23 Times in 22 Posts
Thanked 20,965 Times in 6,721 Posts
meloncollie has a reputation beyond reputemeloncollie has a reputation beyond reputemeloncollie has a reputation beyond reputemeloncollie has a reputation beyond reputemeloncollie has a reputation beyond reputemeloncollie has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Quote:
View Post
(e.g. is there such a thing as an ombudsman responsible for health insurers) or is it just tough?
Ombudstelle Krankenkasse:
https://www.om-kv.ch

Contact per telephone or by mail, available hours listed.

Hope they can be of some help...
Reply With Quote
This user would like to thank meloncollie for this useful post:
  #8  
Old 16.11.2018, 18:02
roegner's Avatar
Forum Legend
 
Join Date: May 2011
Location: Zurich
Posts: 8,058
Groaned at 291 Times in 239 Posts
Thanked 8,665 Times in 4,378 Posts
roegner has a reputation beyond reputeroegner has a reputation beyond reputeroegner has a reputation beyond reputeroegner has a reputation beyond reputeroegner has a reputation beyond reputeroegner has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Did your doctor inform you it is not listed?
Reply With Quote
This user would like to thank roegner for this useful post:
  #9  
Old 16.11.2018, 18:10
curley's Avatar
Forum Legend
 
Join Date: Oct 2006
Location: canton ZH
Posts: 9,067
Groaned at 124 Times in 108 Posts
Thanked 9,681 Times in 5,167 Posts
curley has a reputation beyond reputecurley has a reputation beyond reputecurley has a reputation beyond reputecurley has a reputation beyond reputecurley has a reputation beyond reputecurley has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Quote:
View Post
.......
It seem seems my doctor did send a detailed explanation but the insurer has dismissed it.....
And you and your doctor went through with it anyway?
Which is absolutely okay as you can decide on anything yourself. Except who's paying.

There are drugs which are not on the list. If you want them anyway, you need additional health insurance (Zusatzversicherung) and should you go for that (too late for this case) you better read the small print - the thing you will want might again be excluded.
Reply With Quote
  #10  
Old 16.11.2018, 18:22
Forum Veteran
 
Join Date: Jan 2010
Location: Zurich
Posts: 532
Groaned at 79 Times in 35 Posts
Thanked 514 Times in 250 Posts
Kedi is considered knowledgeableKedi is considered knowledgeableKedi is considered knowledgeable
Re: Insurer refusing to pay for drugs

I can't help feeling your doctor was in the wrong to treat you with drugs that your insurer would not pay for. Did he explain this to you and ask for your approval? Are you sure it is the only drug that can treat it? It might be best to appeal to the ombudsman. Good luck.
Reply With Quote
The following 2 users would like to thank Kedi for this useful post:
  #11  
Old 16.11.2018, 18:52
Newbie
 
Join Date: Nov 2018
Location: Basel
Posts: 8
Groaned at 0 Times in 0 Posts
Thanked 1 Time in 1 Post
MrJolly has no particular reputation at present
Re: Insurer refusing to pay for drugs

Quote:
View Post
Ombudstelle Krankenkasse:
https://www.om-kv.ch

Contact per telephone or by mail, available hours listed.

Hope they can be of some help...
Thanks
Reply With Quote
  #12  
Old 16.11.2018, 19:00
Newbie
 
Join Date: Nov 2018
Location: Basel
Posts: 8
Groaned at 0 Times in 0 Posts
Thanked 1 Time in 1 Post
MrJolly has no particular reputation at present
Re: Insurer refusing to pay for drugs

Thanks for your responses.

My doctor didnít inform me that the drug was not on the list & there was no mention that I might have to pay for the drug myself - he went through the lab report which clearly states that only carbapenems can treat this particular type of ESBL infection, so thatís what he prescribed. Itís not as though there are any alternatives - anyway I will see what he says next week but I just find it astounding that the liability sits with the patient. This should really be something betwen the doctor and insurer.
Reply With Quote
This user would like to thank MrJolly for this useful post:
  #13  
Old 16.11.2018, 19:06
Forum Veteran
 
Join Date: Dec 2012
Location: Aargau
Posts: 2,095
Groaned at 11 Times in 10 Posts
Thanked 2,639 Times in 1,229 Posts
Mullhollander has a reputation beyond reputeMullhollander has a reputation beyond reputeMullhollander has a reputation beyond reputeMullhollander has a reputation beyond reputeMullhollander has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Beobachter describes the steps to take to object to the rejection of a medical bill by a health insurance company (German):

https://www.beobachter.ch/geld/krank...se-nicht-zahlt
Reply With Quote
The following 4 users would like to thank Mullhollander for this useful post:
  #14  
Old 16.11.2018, 19:09
Forum Legend
 
Join Date: Sep 2010
Location: Neuchatel
Posts: 22,869
Groaned at 544 Times in 416 Posts
Thanked 25,381 Times in 11,638 Posts
Odile has a reputation beyond reputeOdile has a reputation beyond reputeOdile has a reputation beyond reputeOdile has a reputation beyond reputeOdile has a reputation beyond reputeOdile has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Hope the Ombudsman can help. Out of interest, if the doctor Swiss, or newly arrived from afar? Seems very strange that he did not warn you, or check.
Reply With Quote
This user would like to thank Odile for this useful post:
  #15  
Old 16.11.2018, 19:17
Jim2007's Avatar
Forum Legend
 
Join Date: Jun 2006
Location: Kt. Bern
Posts: 3,812
Groaned at 86 Times in 75 Posts
Thanked 4,038 Times in 1,961 Posts
Jim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond reputeJim2007 has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Quote:
View Post
Thatís pretty much what they told me. However, as I pointed out to them the doctor prescribed the only drug that the bacteria showed sensitivity to in the lab test. Crazy rules.
Yes but the doctor is supposed know the rules and seek approval before prescribing the drug or at least advice you that it may not be covered. Your beef is with the doctor Iím afraid.
Reply With Quote
The following 2 users would like to thank Jim2007 for this useful post:
  #16  
Old 16.11.2018, 19:30
swisspea's Avatar
Forum Legend
 
Join Date: May 2008
Location: From one side of lake Zurich to the other...
Posts: 5,758
Groaned at 33 Times in 22 Posts
Thanked 5,396 Times in 2,577 Posts
swisspea has a reputation beyond reputeswisspea has a reputation beyond reputeswisspea has a reputation beyond reputeswisspea has a reputation beyond reputeswisspea has a reputation beyond reputeswisspea has a reputation beyond repute
Re: Insurer refusing to pay for drugs

In my experience, the doctor's will be anything from mildly irritated to livid that the health insurance don't pay for the treatment that is prescribed.

Hopefully your doctor will be the same - I've sent more than one tersely worded letter from my doctor to mine or my child's insurers.
Reply With Quote
This user would like to thank swisspea for this useful post:
  #17  
Old 16.11.2018, 19:40
ipoddle's Avatar
Forum Veteran
 
Join Date: Jan 2008
Location: basel
Posts: 945
Groaned at 20 Times in 13 Posts
Thanked 926 Times in 375 Posts
ipoddle has an excellent reputationipoddle has an excellent reputationipoddle has an excellent reputationipoddle has an excellent reputation
Re: Insurer refusing to pay for drugs

Good luck.. but as a regular recipient of a very expensive, though relatively common, drug.. I can only say that the consultant explained he wouldn't do anything until the insurance company agreed.

Your doctor should have walked through that process first
Reply With Quote
The following 5 users would like to thank ipoddle for this useful post:
  #18  
Old 16.11.2018, 20:16
marton's Avatar
Forum Legend
 
Join Date: May 2008
Location: Kt. ZŁrich
Posts: 10,574
Groaned at 333 Times in 286 Posts
Thanked 13,444 Times in 7,403 Posts
marton has a reputation beyond reputemarton has a reputation beyond reputemarton has a reputation beyond reputemarton has a reputation beyond reputemarton has a reputation beyond reputemarton has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Quote:
View Post
Yes but the doctor is supposed know the rules and seek approval before prescribing the drug or at least advice you that it may not be covered. Your beef is with the doctor Iím afraid.
I agree, at a minimum if you had known you could have sought a cheaper solution. Most prescription drugs are cheaper in Germany and Holland.

I take a daily dose of a prescribed drug not paid by the Krankenkasse; I could buy the same one in Germany for under half the Swiss price. Now there is a generic version which is around 20% of the Swiss price; so far I did not find this generic version is available here!
Reply With Quote
  #19  
Old 16.11.2018, 20:26
fatmanfilms's Avatar
Forum Legend
 
Join Date: Apr 2010
Location: Verbier
Posts: 17,565
Groaned at 279 Times in 228 Posts
Thanked 14,901 Times in 8,296 Posts
fatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond reputefatmanfilms has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Quote:
View Post
I agree, at a minimum if you had known you could have sought a cheaper solution. Most prescription drugs are cheaper in Germany and Holland.

I take a daily dose of a prescribed drug not paid by the Krankenkasse; I could buy the same one in Germany for under half the Swiss price. Now there is a generic version which is around 20% of the Swiss price; so far I did not find this generic version is available here!
If you ever go to the UK, some superdrugs have a pharmacy & they do private prescriptions at cost, about 40% of the cost from Boots. To put this in perspective 6 months supply for £12 so £2 v 24 CHf a month en Suisse. NHS prescription being more expensive.......
Reply With Quote
This user would like to thank fatmanfilms for this useful post:
  #20  
Old 16.11.2018, 20:58
Forum Legend
 
Join Date: May 2013
Location: Nyon
Posts: 2,702
Groaned at 72 Times in 42 Posts
Thanked 3,274 Times in 1,298 Posts
John_H has a reputation beyond reputeJohn_H has a reputation beyond reputeJohn_H has a reputation beyond reputeJohn_H has a reputation beyond reputeJohn_H has a reputation beyond repute
Re: Insurer refusing to pay for drugs

Assume this is the basic medical insurance?

By chance i was looking through mine today and the supplemental says that it covers drugs not included in the basic if prescribed by a doctor.
Reply With Quote
This user would like to thank John_H for this useful post:
Reply




Currently Active Users Viewing This Thread: 1 (0 members and 1 guests)
 
Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Trackbacks are Off
Pingbacks are Off
Refbacks are Off


Similar Threads
Thread Thread Starter Forum Replies Last Post
Ex-employer Refusing to Pay Me TuxedoPants Employment 15 27.07.2014 15:17
Health insurance refusing to pay for accident kaustavghose Insurance 26 04.09.2012 12:07
Pay med bill and/or forward to insurer? Brotherhood of Justice Insurance 16 09.02.2011 12:34
refusing to pay Anthony1406 Employment 6 09.09.2010 12:04
Insurer refuses to pay for prescribed meds axman Insurance 21 02.01.2009 14:19


All times are GMT +2. The time now is 03:21.


Powered by vBulletin® Version 3.8.4
Copyright ©2000 - 2019, Jelsoft Enterprises Ltd.
LinkBacks Enabled by vBSEO 3.1.0