What does a birth defect actually mean?


The birth of a child – a profound emotional experience – is followed by a sudden shock: the baby has a heart defect. Conditions like this which are present at birth are defined as congenital anomalies or disorders, but are more commonly known as birth defects. The cost of medical treatment is covered by the Federal disability insurance (IV) and by supplementary health insurance if taken out before the child is born.

What does a birth defect actually mean?

A congenital heart defect, trisomy 21 (Down's syndrome) or epilepsy: if physical or mental impairments like these are already present when the child is born, we talk about recognised congenital disorders. The term refers to medical conditions that develop prenatally, and which may be caused by a number of different factors. Some birth defects are mild and can be cured, others are more severe and may require lifelong medical treatment.

Birth defects and congenital disorders list

The FDHA Ordinance on Congenital Disorders sets out all the conditions that are considered birth defects for disability and health insurance purposes (in German, French and Italian only). If a birth defect is not on this list, benefits can't be claimed from the Federal disability insurance.

Examples of conditions on the list

Each type of birth defect on the list has been assigned a number.

  • Congenital ADHD / POS, 404
  • Congenital epilepsy, 387
  • Congenital autism spectrum disorder, 405
  • Congenital heart defect, 313
  • Down’s syndrome / trisomy 21, 489
  • Cerebral palsy, 390

When is a medical condition defined as a birth defect?

A mere predisposition to a disease is not considered a birth defect. Only medical conditions present when the child is born are recognised as congenital disorders.

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The child’s age determines who pays

Who covers the cost of treatment depends mainly on the age of the child in question. Federal disability insurance (IV) pays for treatment costs up to the end of the month in which the child turns 20. However, it will only cover the costs if the birth defect is included on the birth defects and congenital disorders list. From age 20 onwards, basic health insurance pays benefits.

An early diagnosis is key

It’s worth reacting quickly if you suspect your child may have a birth defect. Federal disability insurance won't pay claims dating back more than 12 months before your child was registered. The diagnosis and treatment must be well-documented.

When does disability insurance pay, and for how long?

Federal disability insurance pays for all medical measures relating to a birth defect – provided these are strictly necessary – until the insured person’s 20th birthday. The insured child doesn't have to pay a retention fee.

Federal disability insurance may also cover the cost of any aids required, travel to the place of treatment, and accommodation. It might even cover other costs, for example to support the occupational integration of young people with ADHD.

Is AD(H)D a birth defect?

ADHD can be recognised as congenital disorder no. 404 in children who have received therapeutic interventions for ADD/ADHD before the age of nine.

When does health insurance pay for a birth defect?

Once people with birth defects reach age 20, health insurance becomes responsible for benefits related to medical measures. Basic insurance provides the same cover for birth defects as for any other medical condition. Insured persons must pay a share of the costs in the form of the deductible, retention fee and contribution to hospital costs. All health insurers offer the same benefits under basic insurance. You can take out supplementary insurance to cover additional costs.

Prenatal admission is really important

You can start protecting your unborn child during your pregnancy to make sure it has ideal cover if born prematurely or with a birth defect. Your unborn child will be admitted to certain supplementary insurance plans without any restrictions. If your life situation changes at a later date, you can simply cancel the insurance.

Once the child is actually born, its state of health is taken into account when you apply to take out supplementary insurance. Cover can be excluded or restricted if the child is suffering from a medical condition or congenital anomaly.

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