How are dental costs covered under the KVG/LAMal?

Basic health insurance covers dental expenses incurred as a result of serious illness or accident. In the case of illness, the dentist must submit a complete treatment plan to the health insurer before starting treatment.

Note that in this case, the "tiers payants" system applies: the health insurer advances the costs and invoices the patient for the co-payment and deductible.

The dental diseases covered by basic health insurance are listed in articles 17 to 19 of the ordinance on benefits in compulsory health insurance in the event of illness (OPAS). These articles list 18 illnesses for which the full cost of treatment is reimbursed by basic health insurance. In addition, article 19a defines the reimbursement of dental treatment costs for congenital disabilities.

Note that in the event of an accident, the basic insurance covers the costs if no other insurance covers them.

Conversely, routine dental treatments such as cavity treatment, annual check-ups or scaling will be at the patient's expense. Basic health insurance does not cover these treatments. These costs may be covered by supplementary dental insurance. On average, a scaling treatment will cost you between 100 and 200 francs, whereas a cavity treatment can cost you up to 1,000 francs. To avoid these costs, we recommend that you take out supplementary dental insurance.

Accident insurance covers dental expenses in the event of an accident. For a person employed for more than 8 hours a week, the employer's accident insurance (LAA) will cover the costs. Conversely, for a self-employed, retired or unemployed person, the patient's accident insurance will be called upon.

Note that accidents during mastication, accidents due to a "hard bite" while eating, do not constitute an accident.

Invalidity insurance (AI) covers dental treatment if it is necessary for the patient's professional rehabilitation and makes a lasting contribution to the insured person's earning capacity.

It is possible to obtain reimbursements from supplementary benefits for sickness or dental expenses. Note that reimbursements may be limited.

People receiving AVS or AI pensions are entitled to supplementary benefits in cases where expenses are recognized by the federal law on supplementary benefits for old-age, survivors' and invalidity insurance are higher than the determining income. These supplementary benefits are calculated on a case-by-case basis.

Supplementary benefits are only paid in the case of dentists who hold a federal diploma or cantonal license to practice. Dental treatment costs are also reimbursed if the treatment is simple and economical. If the cost of dental treatment exceeds CHF 3,000, an estimate must be submitted to the supplementary benefits organization for approval.

In the case of orthodontic treatment, the bills are often very high, ranging from CHF 7,000 to 15,000. In such cases, it is essential to take out supplementary dental insurance to cover the cost of treatment.