Policy Restriction at the Insurer: Definition, Examples and Duration
Did your supplementary insurance receive a policy restriction? Compando explains definition, difference to rejection and duration with concrete examples.
1. What is a policy restriction at the insurer?
The insurers are not obliged to accept your application for supplementary insurance. They have three options: admission without restriction, admission under policy restriction or complete rejection. A policy restriction arises when the insurer sees an elevated risk due to your health information and excludes certain benefits from protection.
Policy restrictions exist only for supplementary insurance under the Insurance Contract Act (VVG). In mandatory basic insurance (KVG), policy restrictions are not allowed. With the health questionnaire when taking out a supplementary insurance, the insurer determines which benefits are excluded.
2. Policy restriction vs. rejection: where is the difference?
Policy restriction and rejection are often confused. Both decisions apply only to this one insurer. The consequences for you are however very different.
A policy restriction is a partial acceptance. You receive a contract; the insurer however excludes certain illnesses from protection. For all other areas, you remain fully insured.
A rejection is a complete refusal: the insurer rejects your application completely. Other insurers, however, assess the risk differently. If you inquire with several at the same time, you increase your chance of admission.
3. Examples: when does the insurer attach a policy restriction?
Policy restrictions are directly related to the information in the health questionnaire. Two examples show how this works.
Case example 1: Hay fever with alternative medicine wish. A 32-year-old insured from the canton of Bern suffers from pollen allergy and takes out a supplementary insurance for alternative medicine. The insurer admits her, but excludes treatments of hay fever from protection.
Case example 2: Earlier knee operation and hospital wish. A 41-year-old insured from the canton of Lucerne applies for a hospital supplementary insurance. Due to an earlier knee operation, the insurer attaches a policy restriction for further knee treatments. Hospital stays for other reasons remain insured.
Some treatments remain covered for you via basic insurance if they belong to basic insurance. This also includes individual methods of alternative medicine if a doctor who is trained for this applies them.
Compare supplementary insurance with admission chances
The conditions for admission differ strongly between providers. Compare the supplementary insurance before the application. This way you find the suitable provider for your needs.
4. What happens with subsequent policy restrictions?
Insurers can also subsequently attach policy restrictions or adjust the contract if you made untrue or incomplete information in the application. This disclosure obligation violation can have consequences even years after contract conclusion.
Important: disclosure obligation under Art. 6 VVG
The legal basis for subsequent adjustment is the disclosure obligation under Art. 6 VVG. Anyone who conceals or falsely states essential facts in the health questionnaire risks a contract adjustment even years later.
Three possible consequences of a disclosure obligation violation:
- Retroactive benefit refusal: The insurer does not cover already submitted invoices if they are connected with the concealed illness.
- Contract adjustment: The insurer may attach extended policy restrictions.
- Contract dissolution: In severe cases, the insurer can retroactively terminate the contract.
If your life situation changes, you can change or terminate the supplementary insurance only within the notice periods. Due to a subsequent policy restriction, you cannot exit immediately.
5. How long does a policy restriction at the insurer apply?
Good to know: duration usually five years
Policy restrictions are often limited to five years. After these five years, the policy restriction usually no longer applies if nothing else is in the contract.
There are also unlimited policy restrictions, especially for chronic or permanently existing illnesses. How the benefit exclusion is formulated decides whether only a single diagnosis or also all follow-up treatments are affected.
Four steps with a policy restriction:
- Check policy restriction: Which diagnosis or treatment is concretely excluded for you?
- Read policy and AVB: There is the exact scope of the benefit exclusion.
- Compare alternatives: Check the conditions of other providers via the sensible supplementary insurance.
- Note timing of termination: Terminate the existing supplementary insurance only when the new insurer has confirmed your application in writing.
If you can choose between several providers, check the conditions early. This way you also consider the policy restriction periods in your decision.
Compare supplementary insurance by need
Families, adults and seniors have different needs for supplementary insurance. Premiums and conditions differ strongly between providers. Therefore a comparison by benefits package and age pays off.
