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I work for a Swiss company which provides me with accident insurance, which is legally mandated in Switzerland.

Some time ago as I was bicycling home, I crashed (hitting an all-but-invisible obstacle) and sustained several injuries. Most healed quickly, but I ended up with a shoulder problem that has persisted for months.

At first the accident insurance company was cooperative, but after I began to see specialists about my persistent shoulder problems, they sent me a letter saying their doctor, who never examined me, felt the shoulder problems were not accident-related and that therefore they would no longer pay.

I wrote up a timeline of the medical care as well as a detailed dispute letter explaining that I had no pain before the accident, pain from the time of the accident, and no history of activities that could've caused the shoulder problems.

They sent this information to another doctor whom they paid (and who also didn't examine me) who said the condition was most likely degenerative and not caused by the accident. Therefore they continued to refuse to pay.

Assuming I'm telling the truth, and my shoulder injuries clearly date to the accident, what recourse against the accident insurance company do I have at this point?

And does it make a difference in terms of this resource whether or not I'm a Swiss citizen, and whether or not I live in Switzerland?

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  • In addition to whatever's provided under Swiss law (about which I know -0-), the insurance policy's Terms & Conditions may contain provisions addressing disputes, arbitration, or appeal.
    – DavidRecallsMonica
    May 6, 2021 at 16:04
  • Whether you have recourse shouldn't depend on the assumption that you are telling the truth. The recourse itself should consist of a neutral party that can judge whether you are telling the truth or not. At the very least the company should have a firmer basis for rejecting the claim than an assertion about your medical condition made by a doctor who hasn't examined you; that's just absurd.
    – phoog
    Jun 9, 2021 at 20:54
  • @phoog What you find reasonable and what Swiss law allows are not necessarily the same things.
    – Kyralessa
    Jun 10, 2021 at 6:00
  • @Kyralessa more's the pity. I'm about to move to Geneva.
    – phoog
    Jun 10, 2021 at 6:29
  • @phoog Well, try not to have a bicycle accident. ...But it could be worse. If the accident insurance refuses to pay, it goes to my Swiss medical insurance, which has a 300 CHF deductible and a 700 CHF 10% copay. When compared to how much this sort of thing would set one back in the US, it's more of a minor irritation than a financial catastrophe. But it's still annoying.
    – Kyralessa
    Jun 10, 2021 at 6:43

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You can contact the Insurance Ombudsman for initial advice and possible meditation. They are not a judicial body though.

The only judicial recourse, after your first opposition is refused, would be a claim before the appropriate cantonal court.

Would the treatment be covered by LAMal/KVG? If so, you can try contacting your health insurance company and let them fight between themselves. But if you do not live in Switzerland and you are not covered by a LAMal/KVG insurance, this might be different. Citizenship does not matter here.

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  • I've spoken with the health insurance company, and they've said they'll cover it if the accident insurance won't. The trouble is, I have a CHF 300 deductible, followed by a CHF 700 10% copay. I wouldn't have to pay any of these costs if the accident insurance company would cover it as they're supposed to.
    – Kyralessa
    May 10, 2021 at 18:22
  • @Kyralessa Yes, but sometimes the health insurance is willing to dispute it with the accident insurance on your behalf. If they are not willing to, then you have to do it yourself with the help of the ombudsman or a private lawyer.
    – xngtng
    May 10, 2021 at 19:21

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