Medical Examiner (Vertrauensarzt, Art. 57 KVG)

Concept and Legal Basis

Under Art. 57 KVG health insurers appoint medical examiners (Vertrauensärzte) after consulting the cantonal medical associations. These physicians must meet the requirements for practising, have generally practised for at least five years and complete specific further training offered by the Swiss Society of Medical Examiners and Insurance Physicians (SGV). Their task under Art. 57 para. 4 KVG is to advise the insurer on medical questions as well as on remuneration and tariff application; in particular they verify whether the conditions for the duty to pay – notably the WZW criteria – are met. In doing so they are professionally independent and not bound by instructions in their judgement (Art. 57 para. 5 KVG). Disagreements between providers and medical examiners are decided by joint medical examiner commissions.

Role in Cost Approval and Data Protection

In practice the medical examiner matters most for cost approvals of hospital and rehabilitation stays, for expensive medicines outside the specialities list or its limitations, and for services whose reimbursement the KLV expressly ties to the examiner’s recommendation. The filter function is central: under Art. 57 para. 7 KVG the examiner passes on to the insurer only the information necessary to decide on the duty to pay, the remuneration or the justification of an invoice. Providers may therefore send medical information directly and exclusively to the medical examiner without the insurer’s claims staff receiving full diagnostic data. In supplementary insurance under the VVG, medical examiners are involved in a comparable way in medical underwriting, exclusions and claims decisions, though without the mandatory requirements of Art. 57 KVG.

Country Comparison

In Germany the Medical Service (Medizinischer Dienst, MD) performs assessments for statutory health funds under § 275 SGB V; since the 2020 MDK reform act it has been organised as an independent body separate from the funds. Private health insurers use consulting physicians. In Austria the chief and control medical service of the ÖGK performs the approval and control function, for example for medicines subject to prior approval.