Exclusion in Supplementary Health Insurance (Vorbehalt)

Concept and Function

While Swiss mandatory health care insurance must accept every person without medical underwriting (Art. 4 para. 2 KVG), supplementary covers such as hospital, outpatient or dental insurance are private contracts under the VVG in which the insurer may select its risks. The basis is the health declaration in the application: under Art. 4 VVG the applicant must truthfully disclose all material risk facts about which the insurer asks in text form. If the assessment reveals an increased risk, the insurer may decline the application, charge a risk loading or – most commonly in Swiss practice – impose a Vorbehalt, an exclusion that removes a specific condition, its consequences and often certain body regions or types of treatment from cover. The exclusion is stated in the policy and applies solely to the named circumstances; all other benefits remain covered.

Time Limits, Removal and Non-disclosure

Exclusions may be time-limited, for example two to five years after completed treatment, or permanent in the case of chronic conditions. Many insurers review removal on request once freedom from symptoms is medically documented. Unlike daily allowance insurance under the KVG, where Art. 69 KVG limits exclusions to a maximum of five years, the VVG sets no statutory maximum duration. If the duty of disclosure is breached, the insurer may under Art. 6 VVG terminate the contract within four weeks of becoming aware and refuse benefits where the concealed fact influenced the occurrence or extent of the loss; imposing a retrospective exclusion instead of termination must be agreed in the contract. Given the lifelong importance of supplementary cover, careful answering of the health questions is essential for customers.

Comparison with IPMI and Germany

In international private medical insurance the Vorbehalt corresponds to exclusions under full medical underwriting, whereas moratorium underwriting and medical history disregarded terms offer alternative routes without individual exclusions – the latter mainly in corporate groups, which is also typical of Swiss group supplementary contracts. In Germany, private health insurers may withdraw from or terminate the contract under § 19 VVG for non-disclosure; exclusions and risk loadings are common in new business but prohibited in the basic tariff.