In Switzerland, the dentist is in principle not reimbursed by basic insurance: check-ups, treatment of tooth decay and orthodontics are paid by the patient, or by a dental complementary insurance policy if they have taken one out. Basic insurance pays only in cases set out in a closed list — certain serious illnesses, an accident that no accident insurance covers, certain congenital disorders. The Federal Office of Public Health puts it simply: dental care is, in principle, not covered by compulsory insurance.
What is not reimbursed
Ordinary fillings for tooth decay and orthodontic costs, such as children's braces, are not reimbursed by basic insurance. The same goes for check-ups and routine dental hygiene. These costs are paid by the patient, or by a complementary insurance policy if they have taken one out.
The three cases provided for by law
The law provides for three situations in which basic insurance covers dental care: where it is caused by a serious and unavoidable disease of the masticatory system; where it is caused by another serious illness or its after-effects; and where it is needed to treat a serious illness or its after-effects.
These three cases are not open to free interpretation. The Health Care Benefits Ordinance lists them exhaustively, article by article: diseases of the masticatory system, the other serious illnesses concerned, the care needed for medical treatment, and a list of congenital disorders. Anything not on it is not covered.
For diseases of the masticatory system, the ordinance distinguishes six groups: certain dental diseases, diseases of the tooth-supporting structures, of the jawbone and soft tissue, of the temporomandibular joint, of the maxillary sinus, and certain dysgnathias. In each group only the listed conditions are covered, and only if they can be classed as a disease. The ordinance also covers a general anaesthetic when covered dental care cannot be given without one, or when care that is not covered cannot be given without anaesthesia because of a serious mental or physical disability; in that second case the anaesthetic is paid for, but not the dental care itself. The full list is in Articles 17 to 19a of the ordinance.
The third case is the least known. The ordinance covers, for example, dental care needed during a heart-valve replacement, radiotherapy or chemotherapy for a malignant condition, or in cases of sleep apnoea: the dental treatment is then paid for because the medical treatment depends on it.
When basic insurance steps in for one of these cases, it does so on the usual terms: the deductible and the co-payment apply as for any illness. A recognised dental treatment is therefore not necessarily reimbursed in full; what you pay yourself depends on the deductible chosen and on what has already been paid during the year.
In practice, it is the dentist who makes the diagnosis, and that diagnosis decides whether the condition is on the list. When expensive treatment is being considered, it is useful to ask the dentist whether it falls under one of the articles of the ordinance, and to have the insurer confirm cover before starting. If cover is refused, asking for the reason in writing tells you what the refusal is based on.
Congenital disorders
Dental treatment linked to a congenital disorder on the ordinance's list is covered by basic insurance when it is needed after the age of 20, or before that age for an insured person who is not covered by federal disability insurance. Before 20, it is in principle disability insurance that pays.
After an accident
Basic insurance also covers the treatment of injuries to the masticatory system caused by an accident. But it only steps in on a subsidiary basis: the law states that it covers accidents to the extent that no accident insurance is liable for them.
For an employee, it is therefore the employer's accident insurance that pays: the Accident Insurance Act expressly includes outpatient treatment provided by a dentist. For everyone else, notably children, people not in gainful employment and uninsured self-employed people, it is basic insurance that steps in, with its deductible and co-payment.
And dental complementary insurance?
Ordinary dental care can only be covered by complementary insurance, governed by the Insurance Contract Act (VVG/LCA) and not by the LAMal. There the insurer is free to accept or refuse the application, to ask health questions and to impose reservations or waiting periods, particularly for orthodontics.
- Compare the reimbursement rate, the annual ceiling and the waiting period, which vary widely from one product to another.
- For children, check whether orthodontics is covered and from when: it is often the most expensive item.
- Answer the health questions accurately, as for any complementary insurance: it is on these answers that the insurer decides.
My dentist costs a fortune: what can still lower the bill
When none of the cases provided for by law applies and no complementary policy pays, the bill stays with the patient — but not always in full.
- Ask for a written estimate before major treatment. It lets you compare quotes and, if one of the ordinance's cases might apply, submit it to the insurer before treatment starts.
- Deduct the costs from your taxes. For federal direct tax, dental costs you pay yourself count as illness costs, except purely cosmetic treatment such as whitening, and the part that exceeds 5% of income, calculated after the deductions in Articles 26 to 33 of the Act, is deductible; for cantonal tax, each canton sets its own threshold.
- Supplementary benefits. Cantons reimburse dental treatment costs to people receiving annual supplementary benefits (EL/PC) to the AHV/AVS or IV/AI; each canton specifies which costs and may limit reimbursement to what is economical and appropriate.