Hello everyone,

I’m currently in my 20th week of pregnancy, and due to my medical history, the obgyn stated it is a high risk one.
For my specific case, since week 5 I’ve had to take daily anticoagulants prescribed by the doctor, including Clexane (enoxaparin) and Aspirin.

I have premium health insurance from Assura (the most basic model) and supplementary from Sanitas.

I would appreciate your advise with the following questions:

1) I’ve been purchasing the required medication from pharmacies which were near my home/ the doctor’s practice. Assura refused to reimburse all the invoices I sent them so far, claiming that these were unauthorized stores. Unfortunately only now I realized that my insurance model has that horrible restriction...
Is there a way to turn this around and get the reimbursement?
BAG states that all required additional exams + medication connected to high risk pregnancies must be covered by the basic insurance. Therefore, although I made a mistake and did not follow Assura’s policy, this situation seems extremely unfair.
In case Assura continues to refuse to pay, could I somehow get the reimbursement through my supplementary insurance (which is Sanitas)?

2) Unrelated to the high risk pregnancy: in the 1st trimester screening, the doctor requested in the blood tests the standard assessment for trisomy risk, and also additional tests for IgM and IgG for infections (toxoplasmosis, cytomegalovirus and rubeola).
Assura covered the costs for the first part, but not for the infections. Is this standard? Could the supplementary insurance cover these remaining tests which were not covered by the premium?

Thanks in advance for the help.

Kind regards,
Bruna

You did not follow the requirements that came with your contract, how are they beeing unfair?

Regarding Santitas, you would have to ask. It depends on what kind of supplementary insurance you have with them.

About Assura not accepting charges for additional test. Have your doctor write them a letter stating why those were necessary.

I'm guessing you have the PharmMed model from Assura which requires medication be purchased from specific pharmacies in Switzerland. The (rather limited) list is published on their website. Unfortunately, there's little you can do legally as this is part of your contract and in exchange, you got a discount on the insurance premium.

Your supplementary insurance will also not paid the bills as those medications are covered by the basic insurance and therefore not covered by the supplementary policy. They are covered by the basic in the sense that Assura would've paid had you followed the rules of your particular plan. Supplementary insurance is generally not meant to provide "duplicate" coverage.

Related to your second question on the toxoplasmosis and other testings which are not covered by the basic insurance as defined by the basic insurance coverage, yes, those tests will *likely* be covered by Sanitas from your supplementary policy. However, exactly what and how much coverage will depend on what supplementary policy you took out from Sanitas and we can't answer that here. You should send the bill including the statement from Assura clearly showing what they did not cover together to Sanitas and they will let you know what's covered for your specific policy.

Many thanks for your answers and advice. Will post an update after the resolution.

Updates:

- We were able to convince Assura to cover approx. 50% of the medications I bought at the wrong pharmacies.

- Sanitas refused to pay for the toxoplasmosis test. On the phone their customer service said they would pay, and asked to send the invoice and the refusal from Assura to an email. When I did that, it took them a month to analyze and they ended up refusing without further clarification. I am still challenging them on the claim.

It would seem you are not the only one as there are other expectant mothers on other forums mentioning the fact that they were trying to get the toxiplasmosis check reimbursed.
The good side is that you’ve got 5 years to make your claim and support your request.
Hope it works out for you.

Are you sure it’s five years for supplementary insurance. I thought it was only two years contrary to the basic insurance which is five years.

Good point, it might be two.