If you use too many alternative medical treatments, your insurance will cancel your benefits.
Author: Sharon Zucker
15.10.2024, 07:45
A 26-year-old woman from the canton of Friborg has already had ten back operations. She suffers from severe, chronic pain and relies on regular medical massages. Until now, Groupe Mutuel‘s supplementary insurance has covered these massages. A total of 18 per year – one every three weeks.
Letter to all insured persons
At the end of June, like all other additionally insured people from Groupe Mutuel, she received a letter: If you make “excessive” use of alternative medical treatments such as massages, acupuncture or osteopathy, there are restrictions on reimbursement. Or Groupe Mutuel requires additional proof, such as a doctor’s report. This must prove that the treatments are really needed for therapeutic purposes.
An employee of Groupe Mutuel explained to the young woman on the phone that she would only receive a maximum of nine treatments per year. Regardless of whether there is a report from the doctor or the therapist. Instead of every three weeks, she can now only go to therapy every six weeks to relieve her pain. Her quality of life has been greatly reduced as a result, she tells the SRF consumer magazine “Espresso”. She can also only work 50 percent and cannot afford the treatments in addition to the premium.
“Espresso” contacts Groupe Mutuel and asks why the young woman is being denied urgently needed massages. Groupe Mutuel writes: «In case of serious illness […] “We will request a report from a doctor in order to assess this more precisely and, if necessary, to take on further meetings.” The woman was incorrectly informed on the phone and we apologize for that.
Great uncertainty and restrictions
Many insured people are of the opinion that Groupe Mutuel changed their insurance conditions in the middle of the year. However, this is not correct: services that are covered by the supplementary insurance must be effective, practical and economical. These conditions have always existed, as the health insurance ombudsman confirms. How the health insurance companies check these criteria varies.
However, in order to refuse further treatment, a report from a doctor or therapist is required, according to the ombudsman’s office. This is the only way to check the criteria for effectiveness, practicality and cost-effectiveness.
This is what the health insurance ombudsman says
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The Health Insurance Ombudsman advises insured people to request a detailed medical report from their doctor that answers the following questions:
- Conditions Treated.
- Improvements noted after each treatment.
- Therapy frequency of further treatments in order to noticeably improve the state of health.
- Therapeutic approach to be pursued.
- Consequence for the patient if treatment is stopped.
According to the ombudsman’s office, if insured persons have already undergone classical medicine therapies – for example physiotherapy – before receiving alternative medical treatment through basic insurance, the report must state why the classical medicine therapy was stopped. The report can then be submitted to the supplementary insurance company.
Apparently Groupe Mutuel has been generous so far and has simply taken over many services. Now it is tightening the screw because more and more insured people are receiving more and more alternative medicine services and this is becoming too expensive for the health insurance company. Without medical evidence, Groupe Mutuel only covers five to eight alternative medical treatments per year.
“90% unlimited” is not unlimited
If additional insurance says that it covers costs up to 5,000 francs, this does not mean that you can receive any benefits up to this amount. The criteria of effectiveness, practicality and cost-effectiveness must also be met in this case. This also applies to Groupe Mutuel’s “90% unlimited” model.
