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Old 16.11.2018, 15:46
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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.
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Old 16.11.2018, 16:38
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Re: Insurer refusing to pay for drugs

Things like that make you want to Molotov your insurers office.
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Old 16.11.2018, 16:42
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Re: Insurer refusing to pay for drugs

I recommend you ask your Dr. to appeal their decision.
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Old 16.11.2018, 17:31
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Re: Insurer refusing to pay for drugs

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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?
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Old 16.11.2018, 17:44
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Re: Insurer refusing to pay for drugs

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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.
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Old 16.11.2018, 17:51
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Re: Insurer refusing to pay for drugs

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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.
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Old 16.11.2018, 17:58
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Re: Insurer refusing to pay for drugs

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(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...
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Old 16.11.2018, 18:02
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Re: Insurer refusing to pay for drugs

Did your doctor inform you it is not listed?
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Old 16.11.2018, 18:10
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Re: Insurer refusing to pay for drugs

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.......
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.
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Old 16.11.2018, 18:22
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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.
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Old 16.11.2018, 18:52
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Re: Insurer refusing to pay for drugs

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Ombudstelle Krankenkasse:
https://www.om-kv.ch

Contact per telephone or by mail, available hours listed.

Hope they can be of some help...
Thanks
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Old 16.11.2018, 19:00
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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.
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Old 16.11.2018, 19:06
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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
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Old 16.11.2018, 19:09
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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.
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Old 16.11.2018, 19:17
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Re: Insurer refusing to pay for drugs

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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.
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Old 16.11.2018, 19:30
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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.
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Old 16.11.2018, 19:40
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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
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Old 16.11.2018, 20:16
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Re: Insurer refusing to pay for drugs

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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!
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Old 16.11.2018, 20:26
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Re: Insurer refusing to pay for drugs

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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.......
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Old 16.11.2018, 20:58
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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.
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