Health Insurance (Krankenversicherung)
Health insurance covers the cost of medical treatment, preventive care, and in some cases loss of income due to illness, and is organized in many countries as a dual system of statutory and private cover.
Comparison profile
- Trigger
- Indemnity
- Insured interest
- The cost of medically necessary treatment, prevention, and medication, and, in certain forms, loss of income during incapacity for work; in Switzerland this includes the individual's legally mandated basic health-care cost interest under the obligatory basic insurance (KVG/LAMal).
- Rating basis
- Flat per-capita premium by region and insurance model (Swiss basic insurance, no individual risk rating), Income-dependent contribution (German GKV), Entry age, health status, and benefit scope (private cover)
- Typical limits
- Swiss basic insurance benefits are defined exhaustively by law with no aggregate sum-insured cap; private cover benefit scope and reimbursement level are defined by the chosen tariff.
- Typical deductibles
- Swiss basic insurance applies a statutory annual deductible chosen between CHF 300 and CHF 2,500 plus 10% co-insurance up to an annual cap; private cover deductible and co-payment levels vary by tariff.
- Target segments
- Private individuals and residents, Employees, Self-employed individuals, High-income earners eligible for private cover
Insured events
- Illness requiring medical treatment
- Accident, where not covered by mandatory accident insurance
- Medically necessary hospitalisation
- Preventive checkups and screening
- Medication and therapy costs
Key exclusions
- Cosmetic or non-medically-indicated treatment
- Experimental treatments not meeting recognised efficacy criteria
- Treatment abroad beyond the applicable tariff, absent supplementary cover
- Pre-existing conditions in individually underwritten private cover
Compulsory insurance
- Switzerland: basic health insurance (Grundversicherung/assurance obligatoire des soins) is compulsory for every person resident in Switzerland under Art. 3 KVG (Bundesgesetz über die Krankenversicherung, SR 832.10).
- Germany: statutory health insurance (GKV) is compulsory for most employees and their dependants under Section 5 SGB V, with an opt-out to private health insurance (PKV) above the income threshold (Versicherungspflichtgrenze) or for the self-employed and civil servants.
Concept
Health insurance covers the economic consequences of illness and accident, in particular the cost of medical treatment, preventive checkups, and medication, as well as, in certain forms, loss of income during incapacity for work. It is among the fundamental social and individual insurance lines in almost all developed economies.
Health Insurance Systems
In many countries, particularly Germany, a dual system exists comprising statutory health insurance (GKV), based on the solidarity principle and income-dependent contributions, and private health insurance (PKV), based on individual risk assessment and equivalence-based premium calculation. In other jurisdictions, such as Switzerland, a general insurance mandate applies within a uniform, state-regulated private-law system instead.
Tariff Design in Private Health Insurance
Private health insurers calculate their tariffs on the equivalence principle based on entry age, health status, and the selected scope of benefits; to offset the rising cost of illness with age, an aging reserve is built up, intended to enable a premium that remains largely stable over the contract term.
Comparison and delineation
Basic health insurance is regularly complemented, rather than substituted, by supplementary products that address gaps it does not cover: hospital supplementary insurance upgrades ward, hospital choice, and physician choice beyond the general ward; daily sickness benefit insurance replaces lost income during incapacity for work, which basic cover generally does not; and dental supplementary insurance closes the gap between statutory dentures subsidies and actual treatment cost. These complementary covers presuppose and build on the underlying basic or statutory health insurance rather than competing with it.