841.3.21 ELKVFOMPCF

CH-FR

Art. 10 Ordinance on the reimbursement of illness and disability costs for supplementary benefits (OMPCF) - Dental Treatments

Recognized Medical and Disability Expenses

Open official source Full Act (23 Articles) Machine-readable Markdown (.md)

Art. 10 ELKVF - Dental Treatments · Dental Treatments

1. Costs for simple, economical, and appropriate dental treatments will be reimbursed.

2. Only treatments carried out by a dentist with a federal diploma or with a cantonal license to practice are permitted. Crowns, bridges, or dental prostheses directly adjusted by a dental technician will not be reimbursed.

3. If the costs of a dental treatment (including lab costs) are expected to exceed 1000 Swiss Francs, a cost estimate must be submitted to the cantonal compensation office before the treatment.

4. Cost estimates and invoices must be submitted in accordance with the tariff positions according to the UV/MV/IV tariff. Only the minimum tax point value will be considered.

5. To determine whether the treatment meets the criteria listed in section 1, the cantonal compensation office requires the necessary information and, if necessary, submits the situation to its consulting physician. It then provides a statement for the insured person and the treating physician.

6. Approval of the cost estimate by the cantonal compensation office cannot be equated with a guarantee of coverage. However, the insured person can expect that there will be no professional objections to a treatment within the scope of the approved cost estimate. Reimbursement is only possible if the maximum amount for the reimbursement of illness and disability costs has not been reached and if the person still qualifies for the annual supplementary benefit at the time of treatment.

7. At the explicit request of the treating dentist, which must be submitted when preparing the cost estimate, the invoice can be reimbursed directly to the dentist, provided the treatment corresponds to what was approved by the cantonal compensation office.

← Art. 9 ELKVF Ordinance on the reimbursement of illness and disability costs for supplementary benefits (OMPCF) - Principles Art. 11 ELKVF →

Court Decisions Applying This Provision (16)

608 2025 1 · fr (Art. 10 Abs. 1 ELKVF)

Supplementary Benefits Recipient Denied Coverage for Extensive Dental Implants

This cantonal regulation, which limits reimbursement to necessary expenses under Art. 14 Abs. 2 ELG, is part of the legal framework justifying the rejection of costs above the established limits, although it is not explicitly cited in the dispositive orders I-IV.

608 2023 34 · fr (Art. 10 Abs. 1 ELKVF)

Claimant Appeals Denial of Coverage for Lower Jaw Partial Cast Prosthesis

The court confirmed the decision to only cover costs for simple, economical, and purposeful dental treatment as defined by this provision.

608 2022 197 · fr (Art. 10 Abs. 1 ELKVF)

Recipient v. Social Insurance Office (Dental Treatment Coverage)

The court confirmed the administrative decision which limited reimbursement to costs for simple, economical, and appropriate dental treatments.

608 2019 101 · fr (Art. 10 Abs. 1 ELKVF)

Benefits Recipient Challenge to Limited Dental Treatment Reimbursement

This cantonal provision, based on the delegation in Art. 14 Abs. 2 ELG, sets the criteria that dental treatment must be simple, economic, and appropriate, which the court used to confirm the decision not to reimburse all costs.

608 2019 101 · fr (Art. 10 Abs. 3 ELKVF)

Benefits Recipient Challenge to Limited Dental Treatment Reimbursement

This provision mandates submitting a cost estimate for dental treatments exceeding CHF 1,000 before treatment, which frames the context of the approved estimate versus the final treatment.

608 2019 101 · fr (Art. 10 Abs. 5 ELKVF)

Benefits Recipient Challenge to Limited Dental Treatment Reimbursement

This provision governs the review process by the cantonal compensation office using its consulting dentist to determine compliance with criteria, justifying the assessment made by the lower authority.

608 2019 101 · fr (Art. 10 Abs. 6 ELKVF)

Benefits Recipient Challenge to Limited Dental Treatment Reimbursement

This provision clarifies that approval of a cost estimate does not equate to approval of costs, which is central to why the final costs were not fully covered.

608 2016 6 · fr (art. 10 al. 1 OMPCF)

Appellant v. Compensation Fund (Dental Coverage Dispute)

The court confirmed the decision based on the finding that the dental treatment did not meet the criteria of simplicity, adequacy, and economy specified in this article.

608 2016 6 · fr (art. 10 al. 4 OMPCF)

Appellant v. Compensation Fund (Dental Coverage Dispute)

Cited in the reasoning section concerning the conformity of invoices with the official tariffs, directly related to the calculation of the reimbursed amount.

608 2016 6 · fr (art. 10 al. 5 OMPCF)

Appellant v. Compensation Fund (Dental Coverage Dispute)

Cited as the basis allowing the cantonal compensation fund to seek necessary information and submit the situation to its consulting dentist to determine if the treatment meets the statutory criteria.

608 2014 80 · fr (Art. 10 Abs. 1 ELKVF)

Claimant v. Social Security Fund (Denture Replacement Reimbursement)

Cited as the specific cantonal regulation limiting cost reimbursement to simple, economical, and appropriate dental treatments.

608 2014 80 · fr (Art. 10 Abs. 2 ELKVF)

Claimant v. Social Security Fund (Denture Replacement Reimbursement)

Cited to establish that adjustments made directly by a dental technician (not by a dentist) are not reimbursed.

608 2014 80 · fr (Art. 10 Abs. 3 ELKVF)

Claimant v. Social Security Fund (Denture Replacement Reimbursement)

Cited regarding the requirement for submitting a cost estimate for treatments likely to exceed 1,000 Francs.

608 2014 80 · fr (Art. 10 Abs. 4 ELKVF)

Claimant v. Social Security Fund (Denture Replacement Reimbursement)

Cited in the final considerations regarding the required format for submitting cost estimates and invoices based on UV/MV/IV tariff positions.

608 2014 80 · fr (Art. 10 Abs. 5 ELKVF)

Claimant v. Social Security Fund (Denture Replacement Reimbursement)

Cited to describe the process of obtaining an opinion from the insurance carrier's trusted doctor.