Family doctor, care network or HMO, medical advice by telephone: restricted-choice models lower the basic insurance premium, and that is what makes them attractive. But they rest on a precise commitment, and the health insurance ombudsman's office observes that, for some insured people, their rules have become real traps.
What the law says
The insured person may, in agreement with the insurer, limit their choice to the healthcare providers the insurer designates. The insurer then covers only the costs of services provided or prescribed by those providers. The law adds a guarantee: the benefits it makes compulsory are guaranteed in any case. The catalogue of care therefore does not change; what changes is the route to reach it.
The Federal Office of Public Health (FOPH) describes the three families of models. With the family doctor model, the insured person undertakes to consult their family doctor first for any health question or problem. With the HMO model, they first consult a general practitioner at a group practice, who then refers them to a specialist if necessary. With telemedicine, they first contact a telephone consultation service run by medical staff, which advises them and coordinates the next steps.
There are also models that combine several of these features, and others that encourage, for example, the use of generic medicines or certain health apps. The brand name is therefore not enough to know what is required: only the model's regulations say so, and two insurers may give the same name to two different pathways.
In return, the insurer may reduce the premium. Reductions are allowed only for differences in costs resulting from the restricted choice and from the way providers are paid, not for a healthier clientele. Until the insurer has five years of figures, the premium may be at most 20% below that of the standard insurance.
The rules come from each model's regulations
The law does not set out the details of the pathway, nor the sanctions. Each model has its own regulations, sometimes called general terms and conditions: whom to consult first, how to obtain a referral to a specialist, within what time and through which channel. The ombudsman's office notes that these requirements are sometimes very complex, and that most insured people do not read them in detail.
The regulations are handed over or made available when the model is taken out. They can be requested again from the insurer at any time, and it is worth rereading them when the insurer announces a change, since it is their terms that decide whether something is reimbursed.
According to the same report, the sanctions for a breach range from partial coverage of the costs to a complete refusal of benefits. After several breaches, the regulations often provide for the right to move the insured person to the standard model, with free choice of doctor, but with a considerably higher premium.
In its report, the ombudsman's office cites concrete cases: an insured person whose insurer refuses to pay for a consultation because a step in the pathway was skipped, and then offers to move them back to the standard model on the following 1 January, with the corresponding premium. The rule is not new, but it is often discovered when the bill arrives.
The usual exceptions
Priminfo, the Confederation's premium platform, states that in the HMO model this obligation does not in principle apply to the gynaecologist or the eye specialist, who can be consulted directly. The other exceptions, notably for emergencies or stays abroad, are set out in the model's regulations: no federal rule sets them uniformly.
Joining a model, and leaving it
Moving from the standard insurance to a restricted-choice model is possible at any time. Leaving it, or changing insurer, on the other hand, is possible only for the end of a calendar year, with the notice period set by law. Priminfo confirms it: a change in mid-year is not possible in a health network, HMO, family doctor or telephone consultation model.
This asymmetry matters when choosing: a model that does not suit you is kept until the end of the year, rules and all.
A model can also be combined with a higher deductible. Priminfo points out a limit, however: the total discount may not exceed 50% of the amount for the standard model with the 300-franc deductible and accident cover. Combining a model with a high deductible therefore does not reduce the premium without end.
How to avoid a refusal
- Read the model's regulations before choosing it, not after the first consultation.
- Before each consultation with a specialist, obtain the required referral, and keep it.
- Keep proof of each step, with its date: the call to the telemedicine service, the referral from the family doctor or the HMO centre.
- Check in the regulations what applies in an emergency, at night, at weekends and abroad.
- If you dispute a refusal, ask for the reason in writing, then if necessary contact the health insurance ombudsman's office.