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Old 22.11.2022, 10:19
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Health Insurance not reimbursing bill from USA Hospital

Hi,

I received 2 bills from a US hospital where I received ambulatory ER treatment this past summer. I am a US citizen living in CH. I sent the bills with the requested form to my basic health insurance. They sent a Leistungsabrechnung showing first of all only 3 of the 4 indicated bill positions. Secondly, but most importantly, they indicate these positions as not insured. A portion from two positions was partitioned to my franchise, but the balance is not insured and falls as my burden. I have inquired with the insurance and the reason they gave is that foreign hospitital treatments are covered up to twice the amount of the tarif in my home canton (Aargau.) What I don't understand is if they cover the portion up to twice my local tarif, or if as soon as this limit is exceeded, the entire cost is rejected. Anyone know how that works?

My wife works in the Uni hospital in Zurich and estimates my treatment would have cost 3000 CHF there. My total bill is around 7500 CHF. Assuming Aargau is similar to Zurich, would I not expect the insurance to cover around 6000 CHF minus my 1800 franchise?

At the moment I have requested a Verfügung from them to possibly see what my legal rights are. I did send the bills to my secondary insurance provider, which were rejected under the grounds that this is covered by basic insurance.

Thanks
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Old 22.11.2022, 10:30
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Re: Health Insurance not reimbursing bill from USA Hospital

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Hi,

I received 2 bills from a US hospital where I received ambulatory ER treatment this past summer. I am a US citizen living in CH. I sent the bills with the requested form to my basic health insurance. They sent a Leistungsabrechnung showing first of all only 3 of the 4 indicated bill positions. Secondly, but most importantly, they indicate these positions as not insured. A portion from two positions was partitioned to my franchise, but the balance is not insured and falls as my burden. I have inquired with the insurance and the reason they gave is that foreign hospitital treatments are covered up to twice the amount of the tarif in my home canton (Aargau.) What I don't understand is if they cover the portion up to twice my local tarif, or if as soon as this limit is exceeded, the entire cost is rejected. Anyone know how that works?

My wife works in the Uni hospital in Zurich and estimates my treatment would have cost 3000 CHF there. My total bill is around 7500 CHF. Assuming Aargau is similar to Zurich, would I not expect the insurance to cover around 6000 CHF minus my 1800 franchise?

At the moment I have requested a Verfügung from them to possibly see what my legal rights are. I did send the bills to my secondary insurance provider, which were rejected under the grounds that this is covered by basic insurance.

Thanks
You mention ER - was this an accident? If you work and have accident insurance through your employer, that could be an avenue to pursue.

As far as I have always understood the "twice the price in CH" it would be that they would pay up to that amount and not that a bigger bill would invalidate the whole amount.

Who is the "secondary insurance provider"? An insurer with whom you have complementary insurance?

Do you have travel insurance via a credit card or so perhaps?

Also, taking your calculation:
7500 CHF cost in US
3000 CHF hypothetical cost in CH
6000 CHF maximum cover

I would expect insurance to deduct the franchise from the 6000 CHF and hence cover 4200 on which you would pay 10% contribution.

Hence a reimbursement to you for 3780 CHF.
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Old 22.11.2022, 12:05
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Re: Health Insurance not reimbursing bill from USA Hospital

Thanks for your input. No it was not an accident. I had bad abdomal pains, it turned out to be a kidney stone. Thanks for the sanity check. I also expected something along those lines. the complimentary insurer is Sanitas here in CH. I have a package there that claims to cover up to 90% of foreign hospital bills. Between the two I don't believe I am this badly underinsured to have to foot the entire bill myself.
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Old 22.11.2022, 12:32
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Re: Health Insurance not reimbursing bill from USA Hospital

Did you call your insurer and ask how it will work?
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Old 22.11.2022, 12:49
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Re: Health Insurance not reimbursing bill from USA Hospital

Yes, Swiss health insurance covers twice the cost. If you are going somewhere with expensive healthcare you need top-up travel insurance, that’s covers the rest. But I don’t understand why they haven’t paid the part they should pay.
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Old 22.11.2022, 13:20
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Re: Health Insurance not reimbursing bill from USA Hospital

i did call twice, each time they didn’t have an answer and said the specialist wasn’t around. She finally emailed me back stating basically, we cover up to double the CH price, my bill exceeded this and was therefore not covered. Still trying to get ahold of supplemental insurer.
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Old 22.11.2022, 13:53
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Re: Health Insurance not reimbursing bill from USA Hospital

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i did call twice, each time they didn’t have an answer and said the specialist wasn’t around. She finally emailed me back stating basically, we cover up to double the CH price, my bill exceeded this and was therefore not covered. Still trying to get ahold of supplemental insurer.
That doesn’t make sense, as if you have travel insurance, they only pay out once you reach the limit of your health insurance. So health insurance would still have to pay out the 2x then let your travel insurance pick up the rest.
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Old 22.11.2022, 14:17
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Re: Health Insurance not reimbursing bill from USA Hospital

The twice as much comes with a fine print:
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Temporary stay in a non-EU/EFTA country

During a temporary stay in a country outside the EU/EFTA, the costs of emergency treatment for illness or accident (in cases where a return to Switzerland is not possible for medical reasons) will be reimbursed up to a maximum of twice the amount that would be paid if the treatment were provided in Switzerland. In the case of inpatient treatment, this means that the insurer will reimburse no more than 90% of the costs that would have arisen for hospitalisation in Switzerland. This is because, in the case of hospital treatment in Switzerland, at least 55% of the costs are borne by the cantons, which is not the case for hospital stays abroad.
Other medical treatments abroad are not generally covered by compulsory health insurance.
https://www.bag.admin.ch/bag/en/home...r-Schweiz.html

Still CHF 3000 × 0.9 - CHF 1800 = CHF 900 should be reimbursed.

Issue might be that you got a treatment before you have informed the insurance.
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Old 22.11.2022, 16:20
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Re: Health Insurance not reimbursing bill from USA Hospital

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Thanks for your input. No it was not an accident. I had bad abdomal pains, it turned out to be a kidney stone. Thanks for the sanity check. I also expected something along those lines. the complimentary insurer is Sanitas here in CH. I have a package there that claims to cover up to 90% of foreign hospital bills. Between the two I don't believe I am this badly underinsured to have to foot the entire bill myself.
Wow, CHF 7,500 for Kidney stones! Next time have them in South Africa Doctors home visit (twice), MRI and pain killers, CHF 300 in total + pain (that was free )for a few days till they passed by drinking lots of water!
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Old 22.11.2022, 18:49
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Re: Health Insurance not reimbursing bill from USA Hospital

So the take home lesson here is: buy travel insurance before going to the US. As I recall, Swica recommend you do this for any US trip. Other parts of the world they're not so concerned about.
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Old 22.11.2022, 19:25
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Re: Health Insurance not reimbursing bill from USA Hospital

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The twice as much comes with a fine print:

https://www.bag.admin.ch/bag/en/home...r-Schweiz.html

Still CHF 3000 × 0.9 - CHF 1800 = CHF 900 should be reimbursed.

Issue might be that you got a treatment before you have informed the insurance.
Thanks but, this says in case of in patient care, in the german version stationär. in my case it was ambulatory care. Also the insurance gave the “twice the ch price” being exceeded as their reason, and not 0.9 the price…
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Old 22.11.2022, 23:56
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Re: Health Insurance not reimbursing bill from USA Hospital

Could it be that the treatment in Switzerland would have been more conservative thus they won't pay for what might be considered unnecessary treatment.?
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Old 23.11.2022, 07:08
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Re: Health Insurance not reimbursing bill from USA Hospital

Many years ago I had to undergo life-saving emergency surgery in the U.S. My travel health insurance refused to pay claiming it was a pre-existing condition which it clearly was not.

After a two-year battle in court I finally was reimbursed the full amount of $12.000. My physician in Germany said that the same treatment would have cost about €1.500 in Germany.

According to our lawyer, insurance companies cannot always be trusted to pay even if they are contractually obligated. This might be what they are trying in your case.
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Old 23.11.2022, 10:52
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Re: Health Insurance not reimbursing bill from USA Hospital

If you have a medical emergency, have it in the UK. I ended up spending 7 days in a UK hospital, including 5 days in intensive care, this spring. Total amount billed: 0. I was never asked for my insurance, didn't even show my EHIC card, so the NHS didn't even know anything about my insurance.
I shudder to think what I would have been billed here in Switzerland, let alone in the USA.
And despite everything that is said about the NHS, the care I received was outstanding.
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Old 23.11.2022, 12:47
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Re: Health Insurance not reimbursing bill from USA Hospital

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If you have a medical emergency, have it in the UK. I ended up spending 7 days in a UK hospital, including 5 days in intensive care, this spring. Total amount billed: 0. I was never asked for my insurance, didn't even show my EHIC card, so the NHS didn't even know anything about my insurance.
I shudder to think what I would have been billed here in Switzerland, let alone in the USA.
And despite everything that is said about the NHS, the care I received was outstanding.
When I've used the NHS, I've always been proactive in telling them that I'm not entitled to free care. Others I know do this. Sometimes the NHS staff don't bother to follow it up though.

I've spent extended periods of time in Swiss hospitals. I've just been billed my franchise and co-pay.
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Old 23.11.2022, 15:43
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Re: Health Insurance not reimbursing bill from USA Hospital

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At the moment I have requested a Verfügung from them to possibly see what my legal rights are.
Good, the response you describe above is weird. It looks as if going above their maximum is supposed to have them pay zero, which makes no sense.
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Old 23.11.2022, 16:07
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Re: Health Insurance not reimbursing bill from USA Hospital

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Could it be that the treatment in Switzerland would have been more conservative thus they won't pay for what might be considered unnecessary treatment.?
I think this is a good possibility. The hospital gave me a CT scan which was the largest portion of the bill, my wife believes they would have done an ultrasound here. Now, I'm just waiting for their official statement.
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Old 23.11.2022, 17:23
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Re: Health Insurance not reimbursing bill from USA Hospital

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If you have a medical emergency, have it in the UK. I ended up spending 7 days in a UK hospital, including 5 days in intensive care, this spring. Total amount billed: 0. I was never asked for my insurance, didn't even show my EHIC card, so the NHS didn't even know anything about my insurance.
I shudder to think what I would have been billed here in Switzerland, let alone in the USA.
And despite everything that is said about the NHS, the care I received was outstanding.
Same with me when I had an attack (my first one) of kidney stones in the UK. Even though I had to walk with a gown that was much to small, and the cubicle they put me in was filthy, the out patient care was very good.

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When I've used the NHS, I've always been proactive in telling them that I'm not entitled to free care. Others I know do this. Sometimes the NHS staff don't bother to follow it up though.

I've spent extended periods of time in Swiss hospitals. I've just been billed my franchise and co-pay.
Again the same, I told them I lived in Switzerland, gave my address etc but never received a bill!

Now I know the symptoms I just take pain killers and drink plenty of water till they pass. I also use a product bought from a pharmacy Caroni, in Tenero called Steingallen. It works wonders and boy do you know when you pass the stones! I now take a few spoons once a month as a preventative, and have had no problems for 9 years.
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Old 23.11.2022, 20:35
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Re: Health Insurance not reimbursing bill from USA Hospital

Count yourself lucky if you've only received two bills so far.

One thing I hate about the U.S. system is that hospitals are often a patchwork of different companies as opposed to one entity. There's the hospital, the radiologist, the doctor that treats you in the emergency room, the surgeon, etc. etc.

Even if you have local insurance, some of the providers who treat you may not be in your insurance network. You have no idea because duh, it's an emergency and you don't have the luxury of asking who takes which insurance before they treat you!

Rant aside, I hope you're able to get a fair shake from your Swiss insurance.
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Old 23.11.2022, 21:16
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Re: Health Insurance not reimbursing bill from USA Hospital

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I think this is a good possibility. The hospital gave me a CT scan which was the largest portion of the bill, my wife believes they would have done an ultrasound here. Now, I'm just waiting for their official statement.
My last CT was like 500CHF maximum.
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