Birth defects: disability insurance and health insurance benefits
What are birth defects? Which conditions are on the list of birth defects? Comparis explains and tells you when disability insurance or health insurance will provide cover.
28.02.2024
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1. Birth defects: definition
A birth defect is a genetic physical or mental impairment. This means a birth defect must already be present when the baby is born. If it isn’t, the condition will not be recognized as a birth defect.
Good to know: a predisposition to a disease is not considered a birth defect.
2. Health insurance and disability insurance: birth defects list
Not all diseases are considered birth defects by disability and health insurance providers. The Federal Department of Home Affairs (FDHA) ordinance on birth defects contains all recognised defects.
If a birth defect isn’t on this list, you won’t be entitled to disability insurance benefits. The FDHA regularly updates the list.
Birth defects: examples
Hereditary epilepsy
Congenital cardiovascular malformations
Congenital immunodeficiencies
Congenital deafness
Autism spectrum disorders
Diabetes insipidus
Celiac disease due to gluten intolerance
Congenital leukaemias
Trisomy 21 (Down syndrome)
Consequences of congenital infectious diseases (HIV, congenital viral hepatitis)
3. Who pays out in relation to birth defects: disability insurance or health insurance?
The age of the affected person determines who pays out in relation to birth defects:
Disability insurance: pays out until 20 years of age. More precisely, it pays out until the end of the month in which the affected person turns 20 years old. In order for disability insurance to pay out, the condition must be included on the list of birth defects.
Health insurance company: people with birth defects receive the normal basic insurance benefits as of their 20th birthday.
4. What does disability insurance cover in relation to birth defects?
Disability insurance assumes all costs for necessary treatments for the birth defect. Insured persons do not pay any out-of-pocket expenses. The medical procedures covered by disability insurance include:
Recognized drugs as listed on the disability insurance drug list (list of specialities for congenital disorders)
Medical treatments (outpatient or inpatient on a general ward).
Treatment by healthcare professionals.
Therapeutic devices.
Helplessness allowance, intensive care supplement and assistance allowance.
Travel costs to the place of treatment and accommodation costs. This only applies to journeys on the most direct route between the place of residence and the nearest place of treatment. Further information can be found in the relevant disability insurance leaflet (in German, French and Italian only).
5. Birth defects: reverting back to basic insurance benefits
As of their 20th birthday, people with birth defects don’t receive any special cover from insurance companies. This means the benefits provided by basic insurance are the same for birth defects as they are for illnesses.
Birth defects: how much are out-of-pocket expenses?
As with illnesses, birth defects also come with out-of-pocket expenses. These include the deductible, co-insurance and hospital contribution. When choosing your deductible, therefore, consider how much is spent on medical treatment. If it’s more than 2,000 francs per year, the lowest deductible is worthwhile.
Supplemental insurance for birth defects
Supplemental insurance does not cover treatments covered by basic insurance, including birth defects. However, insurers often exclude known conditions from their list of benefits.
Registering your child before birth lets you apply for and receive practically all supplemental insurance, even if birth defects are discovered later. Therefore, register your unborn child with supplemental insurance before birth.
Supplemental hospital insurance reservations
A Comparis analysis shows that, despite registering the baby before birth, most insurers do not include children in supplemental hospital insurance without reservation. After birth, they can exclude benefits for birth defects. Some insurance companies do not allow you to register your unborn child for supplemental hospital insurance.
6. Disability insurance support: registering birth defects
In order to claim disability insurance benefits, you must register your child with the disability insurance office in your canton of residence. You can get the registration form:
At the disability insurance office.
At a OASI office and their branches.
As an online form.
Important: register your child as soon as possible after the birth defect has been identified. Any delay may lead to reduced benefits.
This article was first published on 05.01.2022
