I had a very rare vascular disease worldwide. In Switzerland, the planned operation was cancelled, and afterwards I was refused treatment and referral, even though my condition continued to deteriorate. The reason for all cancellations and refusals was the same — this disease is not surgically treated by Swiss surgeons. As a result, I was forced to undergo the operation abroad at my own expense. The procedure was successful, and the diagnoses were confirmed. I am currently dependent on social assistance.
I have basic health insurance, and the social services were prepared to send me (through my treating physician) to any clinic within Switzerland. For treatment abroad, however, they required a second medical opinion. I was unable to obtain such a second opinion because Swiss doctors had no experience with my diagnosis.
Is it possible to request partial or full reimbursement of expenses from social services if the surgery was medically necessary and in fact not available in Switzerland?
I would expect that reimbursement is possible but requires pre-approval. The second opinion the insurance demanded is the first step of this process, the confirmation of the diagnosis and affirmation that you needed the treatment in the first place.
Recently, I visited my insurance company, Helsana, and spoke with one of its employees. However, he turned out not to be a specialist but an ordinary agent who deals with offers. He provided me with the email addresses of the insurance company’s departments which, according to him, handle complex insurance cases.
It is still unclear to me how to properly compose a letter in order to effectively request reimbursement.
Where can I get advice from a specialist who can help me request the reimbursement more effectively?
The idea isn’t very practical. A second opinion from a foreign specialist would not have helped much, because the insurance was acting as the party trying to avoid paying in the first place. If they are already unwilling to approve the treatment, they have no incentive to accept an external opinion that contradicts their own assessment. In such a situation, negotiating with them just to obtain a second opinion doesn’t lead anywhere — they simply use it as a procedural barrier rather than a genuine medical requirement.
There is an Ombudstelle Krankenversicherung, however I don’t know whether your question falls within their remit. You could try asking, though - nothing ventured, nothing gained.
I know people who were treated abroad and the cost was picked up by their KK. However, in each case this required approval from the KK beforehand, with documentation proving that your requested treatment was not available in Switzerland, as well as documentation as to what other options available here were given, and why those were not sufficient or followed.
Don’t answer this here, but something you may want to consider when seeking advice or appealing: What prompted you to take seek treatment abroad without KK pre-approval? Was there an emergency?
Borderline will talk out of my ass now, but I know a person (resident in CH) who got a one-time approval to get surgery done in the US for a lab-grown aortic graft placement, for a rare case of vasculitis (already a rare disease). My point is Swiss doctors may not do it, but they should know/understand it…? In this person’s case no second opinion was needed AFAIK, it was determined to be a potentially life-saving operation and the best dr for this ultra-rare situation is, apparently, in the US.
Use ChatGPT to prepare a letter explaining that it is a rare disease, that the surgery was not possible in Switzerland, and that it was not done/postponed because the swiss surgeons could not (were not confident enough to) perform it.
The swiss surgeons should be able to get you reports stating that they were not doingh the surgery due to the increased risks given their expertise (number of similar cases they had treated). Do you have an electronic dossier (DEP)?. It could be that there you find the swiss surgeons reports for your discussions.
The swiss law states something like if the treatment in Switzerland exposes the patient to increased risks of post-op deficits or life threatening. It is not very clear, but there have been cases in the past where the courts have considered this (treatment in Switzerland has increased risks to the patient). Again, use chagGPT or whatever AI you use to get a report on cases similar to yours that you can reference on your letter.
It can be covered after the surgery. You need to motivate your case. Obviously, before is better and with a second opinion that supported your case, that would make your case stronger, but that seems not to be the case now. Anyways, just prepare the a letter explaining this and all the reports of your case, and ask your swiss doctor to send them to the insurance (I think the letter should come from a doctor). And then follow up. Can take some time and insistence, but if it was more risky for you to have the surgery here in Switzerland, it should be covered.