Basic rules on cost coverage
Seegarten Klinik bills according to the TARDOC tariff. This means that conventional medical services and consultations by all our doctors are covered, minus the deductible and co-payment. All other "non-conventional" measures must be billed as self-pay services. The same applies to very time-consuming and long consultations, as TARDOC time is limited.
Necessary laboratory analyses are discussed together and printed out transparently for you. Non-mandatory services are marked as such ("NPL"). You will also find a summary at the top of the page. Our software is also the only one that calculates the laboratory services covered by the health insurer for you – which is particularly important if, for example, you have a high deductible.
With this list, you can ask your insurer specifically about cost coverage if you wish.
Sample laboratory proposal (in German)
Health insurers keep changing their policies.
Scientifically sound methods suddenly fall victim to cuts, while other unknown, questionable and amateurish methods remain or are even newly added. Sometimes coverage is refused with spurious arguments such as: "Your therapist is not EMR-registered" (the EMR is the supervisory body for self-employed therapists without medical supervision) or "We would cover the treatment if it were carried out by the doctor, but not by the therapist." In the latter case, insurers know very well that this option is not feasible in a busy practice. The trend is therefore clear: popular and useful methods are to give way to less popular, less effective and above all cheap ones. Because of lower demand, supplementary insurance becomes more profitable for health insurers.
Suggested letter from patients to their health insurer when costs are refused despite supplementary insurance
Re: billing of services...
Dear...
I do not accept the refusal to cover the services of Seegarten Klinik.
It is incompatible with the constitutionally guaranteed general freedom of action, the principle of the welfare state and the fundamental right to life to exclude a person with statutory health insurance, for whose chronic illness no generally recognised treatment meeting medical standards is available, from coverage of a treatment method of their choice applied by a doctor, where there is a not entirely remote prospect of cure or of a noticeable positive effect on the course of the illness. I would therefore ask you to have the invoice reviewed by your medical examiner's service.
The doctors at Seegarten Klinik will be happy to provide further information. I would be very grateful for a favourable reassessment, not least because the treatment has helped me.
Yours sincerely
Now to the questions and answers...
Will the services be covered by my supplementary insurance?
Insurer's answer: Yes, if he is a doctor.
Comment: Careful – this may be a confusion with basic insurance benefits.
No, because he is a doctor. If he were a naturopathic practitioner, we would cover the services. Normal doctors do not use these methods...
Comment: The penalty for being overqualified...
No, he is not registered with the EMR (ErfahrungsMedizinisches Register, the register for complementary therapists).
Comment: Here the doctor is being confused with a naturopathic practitioner. The EMR is a sensible quality control for naturopathic practitioners (confusingly, they are also called natural "doctors"). Doctors, by contrast, have their own quality management, supervised by the FMH and the complementary medical organisations united under the umbrella of UNION. Some health insurers also claim that EMR registration is being introduced for doctors. This is not true, and for the reasons above it would be neither necessary nor sensible.
Yes, homeopathy is covered.
Comment: Careful – this could be a misunderstanding. Homeopathy is often taken as a synonym for complementary medicine, but it is only a small part of it. The mistake only becomes apparent when the invoice is submitted and the services are not covered.
No, we do not cover any mandatory services, as we cannot find your doctor, Dr. med. John van Limburg Stirum, on our list of recognised doctors.
Comment: We are on the list of recognised doctors.
Although I have supplementary insurance, none or only a small part of the costs are reimbursed.
Comment: Health insurers often offer different types of supplementary insurance – for example classes I to III, which reimburse services more or less generously. Which class are you in? In addition, insurers are free to recognise or remove services under supplementary insurance. You are then dependent on the insurer's goodwill.
You want to know whether the insurer will reimburse a treatment. In reply, the insurer asks for the doctor to justify the services and send a "detailed" report to your insurer's medical examiner.
Comment: The correct procedure would be exactly the other way round: a written enquiry from the insurer or its medical examiner's service to the doctor who issued the invoice. As the insured person, you can expressly request this. The treating doctor can then answer the questions specifically without disclosing further, possibly unnecessary, confidential information. Such information must not reach just any secretary at the insurer, as that would breach medical confidentiality!
IN ADDITION: some of Seegarten Klinik's treatment methods are unknown to many medical examiners, so arguments of this kind will not usually succeed in getting the services recognised. In such situations we will advise against writing a report, as the work involved has to be invoiced as well and in the end achieves nothing.
The health insurer says that services will not be covered under supplementary insurance because the doctor is not "recognised".
Supplementary insurance was created mainly to cover the services of naturopathic practitioners and non-medical institutions, which often have to be registered with the EMR to be recognised. Doctors, on the other hand, are accountable to the cantonal health directorate and (understandably) do not belong in the EMR. As a result, doctors who provide services outside the KVG fall into a regulatory gap – which many health insurers do not understand.
The doctor is not qualified for autologous blood therapy. You should see a therapist.
A classic example of insurer ignorance. Only doctors can offer blood treatments. But because they are not "conventional", insurers believe that a "qualified therapist", i.e. a non-doctor, must be consulted – in the belief that doctors are only competent in conventional medicine.
Doctors who are qualified to practise autologous blood therapy are trained and certified by a medical society (SAGOS). This applies to Seegarten Klinik.
The treating doctor should call the health insurer and "get them moving".
A phone call from the treating doctor to the medical examiner makes no sense: without a formal enquiry, the examiner has not been briefed, does not know the patient and is expecting nothing, so cannot comment – and in the end only represents the interests of the health insurer anyway.
Other messages from health insurers...
The complementary medicine services are not covered because they were not billed with tax points. Sometimes health insurers even ask us to rewrite the invoices according to TARDOC or to assign the corresponding tax points to the services. Among other things, insurers also argue on the grounds of tariff protection, which they say prohibits the doctor from billing differently or privately.
Comment: The additional services that may be billed with tax points are listed correctly. Unfortunately, this now applies only to acupuncture. Other services (laboratory and therapy) have no tax points, because they are unknown to and not recognised by conventional medicine. So we are simply unable to bill them this way. And using so-called (distant) analogous items is clearly against the law. If one could simply bill TARDOC using analogous items, supplementary insurance would become superfluous – since that is precisely what it is taken out for.
Message from a health insurer to a patient: the treatment "systemic hyperthermia" is a mandatory benefit if the invoice is issued according to contract and tariff (TARDOC).
Correct: this therapy may only be invoiced under TARDOC by radiation oncologists as part of radiotherapy. The insurer apparently failed to take our specialty into account. If we billed as the health insurer recommends, we would be breaking the law. (Notice from santésuisse)
If the doctor uses these services, he should also make sure they are recognised by the health insurers.
Comment: With today's legal requirements (KVG) and the large number of different complementary medicine services, it is practically impossible for a "lone fighter" (in terms of time, staff and finances) to get this through all the necessary administrative levels.
The methods are not "recognised" by the insurer and are therefore not covered.
Comment: Each insurer uses different criteria for covering services. The word "recognition", as insurers put it, is also meant to give the impression that they are experts in complementary medicine and have selected only the truly effective methods for the insured. Far from it! Many insurers often do not even know the methods on their own lists (try it for yourself and ask your insurer about unusual methods that are supposedly "recognised"). Even the "benefit specialists" who decide on the methods are often not doctors – and if they are, they are not thoroughly trained in complementary medicine. Supplementary insurance also has to be profitable for the insurer, so strategic considerations come into play (many cheap, questionable and unknown methods to make the lists look longer). From a medical point of view, we are in any case often astonished at the many ineffective and even dubious methods that have apparently gained "recognition". Equally astonishing: on the lists of "recognised" methods we find not a single diagnostic method, only therapies. Apparently complementary medicine needs no "diagnosis"...
The doctor is obliged to inform you about the costs and tell you that the services may be refused in part or in full.
Comment: All patients receive all the necessary information and explanations in writing from the outset. The information is also available on this website.
Colon hydrotherapy is not covered because the doctor is not "certified" or "recognised".
Comment: The doctor is already "certified" – no further certification is needed. Certification only applies to naturopathic practitioners and therapists who are not doctors. Unfortunately, many health insurers are too inflexible to apply common sense here.
Colon hydrotherapy (and many other complementary medicine methods) would be covered if the doctor billed it with tax points under "conventional medicine".
Comment: Such methods have no items in the conventional medical tariff catalogue, so it is simply not possible to bill them this way. Accordingly, insurers should not be asking us to do so.
Diagnostic laboratory analyses are not covered by supplementary insurance because they are not a naturopathic therapy.
Comment: Every sensible and appropriate therapy is preceded by a sound, serious assessment. What use is the best therapy if it is not the right one...
A patient has a serious chronic illness that may be triggered and made worse by bad teeth. There is hardly any chance of dental restoration being covered by the health insurer.
Example of a reply from the insurer:
"We have examined your details and are pleased to comment. For dental treatment, basic insurance covers services required as a result of illness or accident. Under the contractual provisions, dentists must inform the health insurer of the findings and the planned treatment, using a form of the Swiss Dental Association (SSO), before treatment begins or before further treatment. In addition, cost approval must be requested before treatment.
The planned treatment is not a mandatory benefit of basic insurance. The diagnosed conditions – multiple sclerosis, strong suspicion of bacterially and toxically seeding root-treated teeth, and allergy to dental materials – are not included in the exhaustive list of the Health Care Benefits Ordinance (KLV). Reimbursement of additional services is not permitted under basic insurance.
We must therefore refuse to cover the costs in full. Unfortunately, there is also no supplementary insurance under the Insurance Contract Act (VVG) that provides benefits for such treatment."
Comment: The letter shows that the enquiry was dealt with only by an administrative employee without basic medical knowledge. The details are compared with a list, no match is found – no surprise there – and the claim is refused. Unfortunately, the outcome does not change when a medical examiner assesses it.
A patient receives an invoice from the laboratory and thinks it contains the results of his tests.
Comment: The figures on the invoice are not the test results, but the analysis items with their tax point values.