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Old 19.08.2009, 20:47
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If [health] insurance refuses to pay [treatment out of country while on holiday]

This is the story: I went for a nice week end in Rome and there I suddenly had a health problem.
So I immediately went to a doctor i know. (I have lived in Rome for 6 years) he checked me i carried out all the analysis and it came out I had to stop in the clinic: the doctor said he couldn't allow me to leave back to switzerland as my conditions were not good and i needed an immediate operation ( i lost the way back of my flight).
Now, my healt insurance does not include operation abroad unless it's an emergency, so, I sent them all the papers, a letter explaining the facts and a letter of the doctor explaining that was an emergency.
They are refusing to reimburse me as they state that was not an emergency.
The question is: Who can help me with this? Is there an organization or a group or someone dealing with cases like or similar to mine? I just don't want they win. I just don't want to shut up because this is unfair and they expect me to undergo their decision.

Give me your opinion/help
ah.... I'm fine now!!!
Ciao!
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  #2  
Old 19.08.2009, 20:50
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Re: If the insurance refuses to pay

Do not mean to pry but what sort of surgery did you have?
OK no need to tell me of course but it is difficult to assess without knowing what happened

SOrry for all the trouble you are going through though
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Old 19.08.2009, 20:58
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Re: If the insurance refuses to pay

Ombudsman der sozialen Krankenversicherung

Der Ombudsman befasst sich mit praktisch allen Fragen und Problemen, die zwischen Versicherten und Krankenkassen auftreten können. ...
https://secure.om-kv.ch/html/aufgabe.html

The Ombudsman can help you resolve your dispute with your insurance.
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Old 19.08.2009, 20:59
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Re: If the insurance refuses to pay

As Angela-74 says, without knowing exactly what the problem was it's not possible to offer advice.
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Old 19.08.2009, 21:00
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Re: If the insurance refuses to pay

mmm. it seems i posted my problem under 'food and drink' ... i'm really bad... how do i move it?
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Old 19.08.2009, 21:07
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Re: If the insurance refuses to pay

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This is the story: I went for a nice week end in Rome and there I suddenly had a health problem.
So I immediately went to a doctor i know. (I have lived in Rome for 6 years) he checked me i carried out all the analysis and it came out I had to stop in the clinic: the doctor said he couldn't allow me to leave back to switzerland as my conditions were not good and i needed an immediate operation ( i lost the way back of my flight).
Now, my healt insurance does not include operation abroad unless it's an emergency, so, I sent them all the papers, a letter explaining the facts and a letter of the doctor explaining that was an emergency.
They are refusing to reimburse me as they state that was not an emergency.
The question is: Who can help me with this? Is there an organization or a group or someone dealing with cases like or similar to mine? I just don't want they win. I just don't want to shut up because this is unfair and they expect me to undergo their decision.

Give me your opinion/help
ah.... I'm fine now!!!
Ciao!
Is this operation an approved operation? Then the health insurer should at least reimburse you the amount they would have reimbursed if you were operated in your canton.
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Old 19.08.2009, 21:08
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Re: If the insurance refuses to pay

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Ombudsman der sozialen Krankenversicherung

Der Ombudsman befasst sich mit praktisch allen Fragen und Problemen, die zwischen Versicherten und Krankenkassen auftreten können. ...
https://secure.om-kv.ch/html/aufgabe.html

The Ombudsman can help you resolve your dispute with your insurance.
Goldtop thanks very much. I just checked it and this is exactly what i was looking for. you're great!
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Old 19.08.2009, 21:13
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Re: If the insurance refuses to pay

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Ombudsman der sozialen Krankenversicherung

Der Ombudsman befasst sich mit praktisch allen Fragen und Problemen, die zwischen Versicherten und Krankenkassen auftreten können. ...
https://secure.om-kv.ch/html/aufgabe.html

The Ombudsman can help you resolve your dispute with your insurance.
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Is this operation an approved operation? Then the health insurer should at least reimburse you the amount they would have reimbursed if you were operated in your canton.
I was operated in Rome, not in Switzerland. And the operations abroad are approved by the insurance if you follow a certain procedure i.e. calling the emergency number before getting the operation ( i did it and they also spoke twice with my doctor) and providing this is an emergency operation (and this was certified and subscribed by the hospital it was so).
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Old 19.08.2009, 21:14
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Re: If the insurance refuses to pay

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mmm. it seems i posted my problem under 'food and drink' ... i'm really bad... how do i move it?
No worries, I moved it for you.
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Old 19.08.2009, 21:26
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Re: If the insurance refuses to pay

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I was operated in Rome, not in Switzerland. And the operations abroad are approved by the insurance if you follow a certain procedure i.e. calling the emergency number before getting the operation ( i did it and they also spoke twice with my doctor) and providing this is an emergency operation (and this was certified and subscribed by the hospital it was so).
You might only get a small fraction of the costs you incurred in Rome. The reason is as follows: When the operation is done in your home canton, the home canton pays a substantial part of the expenses and the insurer pays the rest. So the insurer could insist on only paying their share and not the Canton's share.

Those who travel should take additional travel insurance including treatment outside CH.
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Old 20.08.2009, 09:58
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Re: If the insurance refuses to pay

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You might only get a small fraction of the costs you incurred in Rome. The reason is as follows: When the operation is done in your home canton, the home canton pays a substantial part of the expenses and the insurer pays the rest. So the insurer could insist on only paying their share and not the Canton's share.

Those who travel should take additional travel insurance including treatment outside CH.
While this is correct for operations in Switzerland the cover for emergencies abroad is different. See this.

The question here is, was it an emergency (i.e. something that could not have been foreseen) that had to be dealt with while the OP was abroad or, could he have safely returned and had the operation here ?

Without knowing the nature of the illness it’s very difficult to comment.
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Old 20.08.2009, 13:04
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Re: If the insurance refuses to pay

Thanks for your help. I'm reading what's in the site you sent me!
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Old 20.08.2009, 13:25
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While this is correct for operations in Switzerland the cover for emergencies abroad is different. See this.

The question here is, was it an emergency (i.e. something that could not have been foreseen) that had to be dealt with while the OP was abroad or, could he have safely returned and had the operation here ?

Without knowing the nature of the illness it’s very difficult to comment.
The linked page says that the health insurance ID card all Swiss insureds constitutes a European Health Insurance card. This brings an EU element into the dispute.

By and large insurers worldwide count on a large percentage of their customers giving up the claim when appealing its refusal is made time-consuming, insulting and generally onerous. Those with patience who will not be intimidated have a decent chance of success.

This lies also behind the current noisy dispute in the USA over health insurance.
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Old 20.08.2009, 17:14
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Re: If the insurance refuses to pay

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While this is correct for operations in Switzerland the cover for emergencies abroad is different. See this.

The question here is, was it an emergency (i.e. something that could not have been foreseen) that had to be dealt with while the OP was abroad or, could he have safely returned and had the operation here ?

Without knowing the nature of the illness it’s very difficult to comment.
The link says that:
  1. The EU hospital shall accept the patient's insurance card.
  2. The patient must pay the deductibles prevalent in the country of treatment.
  3. The EU hospital can recover its costs directly from the Swiss insurer.
  4. The maximum reimbursement from the Swiss insurer is capped at twice the reimbursement in Switzerland.
Apparently:
  1. The OP paid cash to the EU hospital. That means the EU hospital refused treatment under Swiss insurance cover!
  2. We do not know what hospitals in Rome define as usual patient's contribution.
Personally, I purchase additional insurance cover (from TCS) for full reimbursement for emergencies worldwide. Prevents hassles and can be very valuable.
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Old 20.08.2009, 17:18
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Re: If the insurance refuses to pay

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... By and large insurers worldwide count on a large percentage of their customers giving up the claim when appealing its refusal is made time-consuming, insulting and generally onerous. Those with patience who will not be intimidated have a decent chance of success...
My advice is to also get litigation insurance from an independent insurer. Then you can legally pursue your claims.

Otherwise there is the Ombudsman who will help with particularly scandalous insurer refusals.
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Old 20.08.2009, 20:33
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Re: If [health] insurance refuses to pay [treatment out of country while on holiday]

What this case comes down to is that the OP claims that it was an emergency and the Insurer thinks it was not.

The Insurer will, of course, have the account from the hospital so they will know exactly what the condition was. Also they will probably have a recording of the conversations with the Doctor, as it was made to their emergency number.

The basic insurance is operated on a non-profit making basis so the insurer would have no profit motif in rejecting the claim.

Even if he had extra travel insurance that is for emergencies so he’d still be in the same position.

If the OP is certain that the condition was an emergency then the Ombudsman should be called in.

There's two sides to every question but, so far, we've only heard one.
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Old 26.08.2009, 20:29
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Re: If [health] insurance refuses to pay [treatment out of country while on holiday]

Thanks To All Of You For You Opinion And Advice.
You Have Been All So Nice And Helpful.
I Will Let You Know Howthe Story Ends
...fingers Crossed...
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Old 28.08.2009, 22:27
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Re: If the insurance refuses to pay

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Ombudsman der sozialen Krankenversicherung

Der Ombudsman befasst sich mit praktisch allen Fragen und Problemen, die zwischen Versicherten und Krankenkassen auftreten können. ...
https://secure.om-kv.ch/html/aufgabe.html

The Ombudsman can help you resolve your dispute with your insurance.


Yes, true.
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