When you have an operation, covered by compulsory health insurance and also by a supplementary insurance, you do not expect to have to pay part of the bill. This situation can nevertheless occur, and illustrates the current tensions between health insurers and insured persons.
When policyholders are caught between their health insurance and their doctor, in certain cases, it is the latter’s fees that are in question. After an operation to change her hip prosthesis, a patient found herself with a bill to pay out of her own pocket.
I was asked to pay the difference of more than 3300 francs, because they estimated that the bill exceeded the amount they usually reimbursed for this type of operation
“When I received the bill from the orthopedist, I sent it to my Visana supplementary. They refused to pay the entire bill, saying it was too high. So I was asked to pay the difference of more than 3,300 francs, because they estimated that the bill exceeded the amount they were used to reimbursing for this type of operation”, testifies the patient.
Currently in dispute with her insurer over doctor’s fees, she appealed to the Patients’ Federation. But to resolve the dispute, the task turns out to be complex, because the general conditions mention two rather opaque reference rates: “according to agreed rates” or “according to the usual local rates”, without further detail.
Without convention, opacity prevails
Do the fees of the doctor in question exceed these “usual local rates”? The situation could not be clarified with the insurer, explains Brigitte Kohler, consultant and health insurance expert. The insurer actually speaks of “known”, “usual”, “French-speaking” rates – whereas the French-speaking rate is signed only with the Geneva Doctors’ Association. “In the canton of Vaud, where there is no convention, the control method is not very clear,” underlines Brigitte Kohler.
It is therefore difficult to navigate, due to the lack of transparency in the matter. And this type of dispute is not unique, at least in the canton of Vaud, according to the Patients’ Federation, due to lack of agreement between doctors and insurers.
“Star” doctors?
On the health insurer’s side, Visana claims to rely on existing conventions, in Geneva or in German-speaking Switzerland, to determine whether an invoice is excessive or not. However, certain bills from independent doctors far exceed these thresholds, with insurance going so far as to speak of a handful of “star” doctors in French-speaking Switzerland.
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The fund therefore recommends to its customers not to pay the doctor’s bill directly but to let them negotiate with the practitioner to try to find an agreement. In the event of a scheduled operation, she recommends requesting confirmation of coverage to avoid unpleasant surprises.
Sylvie Belzer
