In its judgment, the Federal Supreme Court (the Court) dismissed the appeal of Helsana Assurances SA (Helsana) against a judgment of the Chamber of Social Insurance of the Court of Justice of the Republic and Canton of Geneva (the Chamber of Social Insurance) dated 24 June 2025. The court confirmed that a former employee residing in France remained subject to compulsory health insurance (OKP) under Swiss law while receiving daily sickness benefits under a private insurance contract governed by the Federal Act on Insurance Contracts (ICA) following termination of her employment in Switzerland.

The insured person, a Swiss national residing in France, had been employed in Switzerland until 31 July 2022. Having become incapacitated for work in January 2021, she received daily sickness benefits from her employer's insurer under a collective ICA policy. Helsana considered that the only benefits paid under a policy governed by the Federal Act on Health Insurance (KVG), and not the ICA, could maintain affiliation to Swiss compulsory health insurance under Regulation (EC) No 883/2004 on the coordination of social security systems. It therefore terminated her OKP coverage as of 1 August 2022 and sought reimbursement of CHF 3’957.20.

The Court confirmed that the insured person fell within the personal and material scope of Regulation (EC) No 883/2004. Under art. 11 para. 2, a person temporarily receiving cash benefits "by reason of or as a consequence of" employment is deemed to continue that activity for determining the applicable legislation. In light of the particularities of the Swiss loss-of-earnings insurance system – under which employers may fulfil their statutory obligation to continue paying wages pursuant to art. 324a para. 4 of the Code of Obligations through either a KVG- or an ICA-based collective policy, the Court held that the application of art. 11 para. 2 could not depend solely on the employer's choice of insurance model. The decisive element is receipt of a cash benefits granted on the basis of an employment relationship, irrespective of the domestic legal regime governing those benefits. Accordingly, recipients of sickness benefits under either the KVG or the ICA must be treated equally and remain subject to the legislation of the State of employment, unless they have exercised a right of option. The Court expressly departed from the guidance of the Institution commune LAMal and the relevant AHV/IV directives (DAA) on this point.

The insured person therefore remained subject to Swiss compulsory health insurance legislation. Helsana’s termination of her coverage and it’s reimbursement claim were consequently unlawful.

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