CHIS - Benefits and conditions

General conditions

Medical prescriptionReimbursements are made only for services provided by medical doctors or for expenses incurred on medical prescription (except for emergency transport), e.g. pharmaceuticals, medical appliances, therapies and treatment by medical auxiliaries and therapists including psychologists and physiotherapy. However, treatments by recognised osteopaths, etiopathy therapists and chiropractors [see Art. II 3.11] may be reimbursed without a medical prescription, up to a maximum of five sessions per calendar year (for what concerns the period running from 1st September to 31st December 2017, this equates to two sessions) [see Art. VI 1.04].

Prior approval is required for reimbursement of the following expenses* (CHIS Rules, Chapter VI, Section 3):

  • transport costs (except in the case of emergency transport)
  • refractive surgery
  • thermal spa therapy, convalescence stays, rehabilitation stays, stays in a respite care home or in a unit for those waiting for space to become available in a suitable establishment
  • home nurses
  • hire or purchase of auxiliary appliances
  • cost of accommodation in a hospital for a family member other than one of the two parents and whose presence is required by the hospitalisation of a child of less than ten years of age.

Requests for prior approval must be submitted in writing to the Third-Party Administrator (UNIQA) at least 14 calendar days before the medical expenses concerned are incurred, except in exceptional circumstances. This deadline is increased to 30 calendar days for expenses for thermal spa therapy. In the absence of a response from the Third-Party Administrator (UNIQA) within 14 or 30 calendar days, as applicable, the request is deemed to have been accepted.

Each request for prior approval must be supported by a medical prescription indicating the treatment, its purpose, its duration and the expected result.  An estimate must be attached to any request for prior approval of the hire or purchase of auxiliary appliances.

Note that expenses incurred without obtaining the requisite prior approval are not reimbursed by the Scheme.

* Not all of these are reimbursable under the Reduced Cover, see the list of benefits to know which expenses you will be reimbursed for. 
 

Prior opinion for dental treatment scheduled to cost more than 25% of the annual ceiling* (CHIS Rules Art. VI 3.05) shall be obtained from UNIQA for any planned dental treatment, prostheses and orthodontics, except in cases of emergency.

Requests for prior opinion shall be made by submitting the form estimate for dental treatment completed by the treating dentist to UNIQA at least 14 calendar days before the start of the treatment.

* Not all of these are reimbursable under the Reduced Cover, see the list of benefits to know which expenses you will be reimbursed for. 
 

Proof of payment – Reimbursements are made only when proof of payment is submitted together with the invoice. In case an advanced reimbursement was made the proof of payment have to be sent to UNIQA without delay after paying the invoice(s) for which the advance was made.

 

Non-reimbursable expenses

Expenses for the following (non-exhaustive list of) items are not reimbursed by CHIS, regardless of your type of cover:

  • Costs resulting from a failure to attend an appointment
  • Products bought on-line
  • Expenses requiring prior approval or opinion, for which no prior approval or opinion was obtained
  • Expenses incurred without medical prescription, except treatment by doctors, including specialists, and emergency transport
  • Expenses for which no proof of payment is provided
  • In case another basic health insurance reimburses the same expenses or provide a similar benefit: any annual deductible and the part already reimbursed by the other insurance.
  • Cosmetic treatments, except in the case of disfigurement of the face or serious burns to the hands, as well as reparatory or reconstructive surgery, unless agreed beforehand (prior approval) and if the surgery is made necessary due to the materialisation of an insured risk, the occurrence of an accident or the onset of an illness less than two calendar years before the Member joined the Scheme.
  • The costs for treatment for the after-effects of a treatment not covered by the CHIS (e.g. cosmetic or rejuvenating treatment or surgery and alternative medicine)
  • Items (e.g. treatments, pharmaceuticals, alternative medicine) not recognised as medical treatment in the country where they were prescribed
  • Treatment provided or prescribed by care providers (hospitals, clinics, doctors and other medical professionals) not recognised as medical professionals and licensed to provide health care services in the country where they operate.

 

Interpretation of the CHIS Rules in the event of silence of the text

The CHIS Rules does not include an exhaustive list of reimbursable treatments and medicines, nor the circumstances required for reimbursement. This allows the reimbursement of new treatments but may also lead to situations where it is not evident from the text of the Rules whether a treatment should be reimbursed or not, i.e. silence of the text. In such cases the reimbursement decision will be taken as set out in Article I 1.04 of the CHIS Rules: “in the event of difficulty in interpreting or applying the Rules, in particular where they are silent on an issue, reference may be made subsidiarily and by analogy to Swiss and/or French legislation governing social security and health insurance matters”.

Guidance on how unusual medical expenses, not evidently covered under the items listed in the table of benefits, are reimbursed can be obtained from UNIQA. In the event there is no current reimbursement praxis UNIQA will consult with CERN before giving an answer.

 

Ex Gratia Payments

The CHIS Rules define ex gratia payments as “a benefit exceeding the reimbursement ceiling or a benefit not listed in these Rules” (see Art. VI 6.02 of the CHIS Rules). Such benefits are granted only in “exceptional circumstances”. By their very nature, “exceptional circumstances” cannot be defined nor listed. Circumstances which may be recognized as exceptional include: natural disasters, physical or mental incapacity, and distress.

Guidance on requesting the benefit and what documents to attach to the request is given by UNIQA on a case by case basis. The procedure for requesting ex gratia payments is described in Information Note 5.

 

Challenging a decision

Should you disagree with a decision taken by UNIQA or CERN in applying the CHIS Rules, the decision can be challenged according to: the procedure defined in Chapter XIV of the CHIS Rules.

A complaint against a final decision by the CERN Director-General may be filed with the Administrative Tribunal of the International Labour Organization (ILOAT) in accordance whit its Statute and Rules.

Updated on: 16/04/2015