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Social Insur­ance

How will I receive fin­an­cial support?

When dia­gnosed with lupus, you sud­denly have sev­er­al social insur­ance pro­viders to deal with. These pro­viders are the man­dat­ory health insur­ance, vol­un­tary private health insur­ance, the employ­er­’s daily sick­ness bene­fit insur­ance, dis­ab­il­ity insur­ance, and the pen­sion fund. 

Wheth­er the health insur­ance cov­ers ill­ness and treat­ment costs or wheth­er dis­ab­il­ity insur­ance cov­ers loss of income depends on sev­er­al factors. Inform your­self early on. Seek advice if any­thing is unclear. 

Health Insur­ance

The Health Insur­ance Act and its asso­ci­ated ordin­ances define the frame­work conditions

The Health Insur­ance Act and its asso­ci­ated ordin­ances define the bene­fits and their con­di­tions for cost cov­er­age by health insur­ance. In prin­ciple, cost cov­er­age is secured. This cov­er­age is sub­ject to vari­ous requirements. 

KVG Found­a­tion
Fed­er­al Health Insur­ance Act (KVG)
Ordin­ance KLV

Non-Approved Med­ic­a­tions

The cov­er­age of extraordin­ary med­ic­a­tion costs that are not lis­ted on the so-called spe­cialty list of the Health Insur­ance Act is assessed accord­ing to the fol­low­ing criteria:

  • The med­ic­a­tion is part of a treat­ment regimen. 
  • The use of the med­ic­a­tion is expec­ted to provide sig­ni­fic­ant thera­peut­ic bene­fit against a dis­ease that could be fatal or res­ult in severe and chron­ic health impairments. 
  • There is no thera­peut­ic alternative. 
  • The costs to be covered must be in reas­on­able pro­por­tion to the thera­peut­ic benefit. 
  • The insur­ance cov­ers the costs upon spe­cial approv­al after pri­or con­sulta­tion with its med­ic­al advisors.

This pro­ced­ure res­ults in some health insur­ance com­pan­ies cov­er­ing med­ic­a­tion costs while oth­ers refuse them. It is there­fore advis­able to obtain pri­or cost approv­al from the health insur­ance com­pany for newer—and espe­cially expensive—medications. Cla­ri­fy this with your treat­ing rheumatologist. 

Some ther­apies, such as physio­ther­apy and occu­pa­tion­al ther­apy, are covered by man­dat­ory health insur­ance with­in the frame­work of the law.

For private health insur­ance, it depends on the insur­ance con­tract and the policy. Cov­er­age of these ther­apies by health insur­ance com­pan­ies is handled differently. 

File a well-foun­ded objec­tion in the case of a refus­al of cost cov­er­age. It is best to do this dir­ectly at the health insur­ance com­pany’s headquar­ters. You will often be suc­cess­ful with this. How­ever, this requires a lot of energy. Per­haps someone from your imme­di­ate circle can sup­port you. A coun­sel­ing cen­ter can sup­port you. The Health Insur­ance Ombuds­man can sup­port you. Oth­er­wise, arti­fi­cial intel­li­gence can also be help­ful in for­mu­lat­ing an objection. 

Dis­ab­il­ity Insur­ance (IV)

The pre­requis­ite for dis­ab­il­ity insur­ance pen­sion bene­fits is inca­pa­city to work as a res­ult of object­ively veri­fi­able health dam­age and object­ively insur­mount­able pain.

Dis­ab­il­ity insur­ance bene­fits include:
  • Early detection/​early intervention
  • Voca­tion­al counseling
  • Integ­ra­tion meas­ures (includ­ing assist­ive devices) and daily allowances
  • Pen­sions
  • Help­less­ness compensation

What bene­fits does the IV cover?

Dis­ab­il­ity insur­ance fol­lows the prin­ciple of integ­ra­tion before or instead of pen­sion. This means dis­ab­il­ity insur­ance pen­sions are only paid when integ­ra­tion meas­ures do not achieve their goal or only par­tially achieve it. The fol­low­ing rules also apply. 

The fol­low­ing should be noted. A pen­sion enti­tle­ment arises at the earli­est six months after regis­tra­tion with dis­ab­il­ity insur­ance. The pre­requis­ite for this is a ful­filled one-year wait­ing peri­od with an aver­age of at least 40% inca­pa­city to work. 
  • You receive daily sick­ness bene­fits from the employ­er usu­ally only from 25% inca­pa­city to work. These bene­fits have lim­ited max­im­um days of receipt. As a rule, this is 720 days. 
  • You receive a dis­ab­il­ity insur­ance pen­sion from a degree of dis­ab­il­ity of at least 40%.
  • You receive a pen­sion from the pen­sion fund from an inca­pa­city to work of at least 40%. Depend­ing on the pen­sion fun­d’s reg­u­la­tions, you receive this in some cases from 25%. Request the reg­u­la­tions of your pen­sion fund if you do not already have them. The rel­ev­ant pen­sion fund is the one with which you were insured dur­ing regis­tra­tion with dis­ab­il­ity insurance. 
  • You receive voca­tion­al integ­ra­tion meas­ures from dis­ab­il­ity insur­ance from a degree of dis­ab­il­ity of 20%. These meas­ures include, for example, retrain­ing, job place­ment, work­place adapt­a­tion, or coaching. 

Work­ing Time Reduction

In the case of a work­ing time reduc­tion, a spe­cial­ist’s find­ings are mandatory.

As soon as it appears that a per­man­ent reduc­tion in work­ing hours or a pos­i­tion with lower pay due to lupus is immin­ent, this reduc­tion must be doc­u­mented in writ­ing and early by lupus spe­cial­ists in accord­ance with the fol­low­ing cri­ter­ia and sub­mit­ted to dis­ab­il­ity insurance.

Such con­firm­a­tion is also import­ant when the losses do not yet entitle you to dis­ab­il­ity insur­ance pen­sion benefits.

Involve dis­ab­il­ity insur­ance well and pro­fes­sion­ally doc­u­mented early when you see that a long-term lim­it­a­tion at the work­place is imminent.

Each reduc­tion level must be doc­u­mented indi­vidu­ally by the treat­ing phys­i­cians, for example:

April 1, 2025 – June 30, 2025 from 100% to 70%;

from July 1, 2025 from 70% to 40%, etc.

The doc­u­ment­a­tion must include the detailed find­ings of spe­cial­ist phys­i­cians for lupus. Gen­er­al prac­ti­tion­ers are not sufficient 

These find­ings must expressly state that the par­tial or full inca­pa­city to work is the res­ult of object­ively veri­fi­able health dam­age and object­ively insur­mount­able pain.

It is worth­while to obtain addi­tion­al ana­lyses to prove this. An example of an addi­tion­al ana­lys­is is mag­net­ic res­on­ance imaging.

The health dam­age must not be the res­ult of psychoso­cial factors. Examples of these factors are unem­ploy­ment, cul­tur­al back­ground, lack of edu­ca­tion, or rela­tion­ship problems.

The phys­i­cians must use clear terms in the report. Vague for­mu­la­tions should be avoided. 

Because lupus is not curable—at least until now—and thus chron­ic pain exists prac­tic­ally for life, it must be clearly stated that the reduc­tion in work­ing hours will be per­man­ent.

If an IV applic­a­tion was pre­vi­ously rejected.

In many cases, an unsat­is­fact­ory dis­ab­il­ity insur­ance decision was once made.

Should a new dis­ab­il­ity insur­ance applic­a­tion then be sub­mit­ted or not? The fol­low­ing points should be analyzed: 

  • Basis for decision of the last dis­ab­il­ity insur­ance application
  • What has deteri­or­ated in the meantime
  • Impact on work capacity
  • Addi­tion­al new dia­gnoses with sound med­ic­al report from lupus specialists.

File an objection

It is always advant­age­ous to file an objec­tion dir­ectly after a neg­at­ive pre­lim­in­ary decision or decision from dis­ab­il­ity insurance.

If a dis­ab­il­ity insur­ance rul­ing has been accep­ted, it can only be changed, if at all, with con­sid­er­able effort. It is best to seek advice from a coun­sel­ing cen­ter regard­ing the cor­rect procedure. 

Fur­ther inform­a­tion about the IV:

www.iv-stelle.ch
www.ahv-iv.info

Social Ser­vices at the Hospital

in case of hospitalization

Fur­ther Information

The Can­cer League offers sup­ple­ment­ary explan­a­tions and examples with the guide “Chron­ic­ally Ill—What Do Social Insur­ance Pro­viders Cov­er?“

The guide can be ordered as a prin­ted ver­sion or down­loaded as a free PDF.

Fur­ther­more, we refer to the book “Ill­ness or Accident—What Next in Your Job” from Beobachter-Edition.

Fed­er­al Supreme Court

The Fed­er­al Supreme Court changed its case law in 2015 regard­ing psycho­so­mat­ic con­di­tions and dis­ab­il­ity insur­ance pensions.

The Fed­er­al Supreme Court is chan­ging its prac­tice for assess­ing enti­tle­ment to a dis­ab­il­ity pen­sion due to soma­to­form pain dis­orders and com­par­able psycho­so­mat­ic con­di­tions. The pre­vi­ously applic­able pre­sump­tion is being aban­doned. This stated that such con­di­tions can usu­ally be over­come with reas­on­able effort of will. In future, the actu­al per­form­ance capa­city of affected per­sons must be assessed in a struc­tured evid­ence pro­ced­ure in an open-ended and case-spe­cif­ic manner. 

Judg­ment of June 3, 2015 | Case ref­er­ence 9C_​492/​2014
Judg­ment of June 3, 2015 | Case ref­er­ence 9C_​492/​2014

Bar­ri­er against renewed dis­ab­il­ity insur­ance applications

Cla­ri­fic­a­tion of case law on con­di­tions without organ­ic cause.

Per­sons with psycho­so­mat­ic con­di­tions whose applic­a­tions have already been rejec­ted can­not re-register with dis­ab­il­ity insur­ance. The Fed­er­al Supreme Court appears to be attempt­ing to lim­it the con­sequences of the recently changed practice. 

With the above judg­ment from June 2015, the Fed­er­al Supreme Court sud­denly aban­doned its restraint imposed since 2004. Instead of con­tinu­ing to assume that insured per­sons can get their med­ic­ally unex­plain­able prob­lem under con­trol them­selves with good will, the actu­al per­form­ance capa­city must now be assessed in an open-ended manner.
In a new judg­ment pub­lished in Novem­ber 2015, the Fed­er­al Supreme Court now strikes some­what dif­fer­ent tones. One could almost get the impres­sion that it already regrets its recent change of course and is ret­ro­spect­ively try­ing to lim­it the con­sequences. Thus, it states that the changed case law is only applic­able to new cases, not to those already decided.
The Fed­er­al Supreme Court will only allow a new applic­a­tion for a leg­ally decided case involving a psycho­so­mat­ic con­di­tion if the health status and work capa­city of the per­son con­cerned have actu­ally changed in the meantime.
Judg­ment of Novem­ber 24, 2015 | Case ref­er­ence 8C_​590/​2015