Exceptionally paid health services

Overview

Article 31 of the Charter of Fundamental Rights and Freedoms guarantees insured persons the right to free health care under the conditions set by law. The access of insured persons to reimbursed services is limited due to limited financial resources, however, the legislation guarantees access to exceptional reimbursement of such services in exceptional cases in the provisions of § 16 of the Public Health Insurance Act. It provides that “the competent health insurance institution shall reimburse, in exceptional cases, health services not otherwise covered by the health insurance, in accordance with the procedure referred to in Article 19 (1a), if the provision of such services is the only option in view of the health condition of the insured person”.

It is the duty of health insurance companies to ensure the best possible reimbursement of treatment while maintaining the stability of the public health insurance system. Health insurance companies’ undertakings must be able to make an appropriate legal interpretation and assessment of the facts, which have their origin in highly specialised and at the same time highly dynamic areas of medicine and economics. Health insurers are therefore not in the position of an institution whose task is merely to assess what medical solution is best for the insured. The task of health insurance companies is to find the intersection between the ideal and the sustainable solution.

This article is devoted to a brief description of the criteria that are, or may be, considered relevant in the context of the decision on extraordinary reimbursement claims defined in § 16 of the ZVZP. These are both criteria related to the interpretation of the concept of a service not otherwise covered by public health insurance, as wel as the only options in thermes of the health condition of the insured and, last but not least, the exceptionality of the case.

Keywords:

extraordinary payment – § 16 of the Public Health Insurance Act