§ 39. Assumption of obligations

(1)        The health insurance fund is deemed to have assumed an obligation to pay for the provision of a health service if, within thirty calendar days after the receipt of the documents on which assumption of the obligation is based, the health insurance fund has not notified the health care provider in writing of its refusal to assume the obligation.

(2)        If there is a waiting list for a health service, the health insurance fund is required to assume the obligation to pay for the health service if the insured person has been on the list and waiting for the health service to be provided, together with assumption of the payment obligation by the health insurance fund, until his or her turn or for longer than prescribed by the maximum length of the waiting list.

(3)        If there is a waiting list for a health service, the health insurance fund shall not assume the obligation to pay for the health service if it is obtained outside the waiting list.

(4)        The assumption of an obligation to pay for the provision of a health service may be refused if:

1)         provision of the heath service is unjustified or the therapeutic indications are insufficient;

2)         the health service is provided to a standard below the general level of medical science;

3)         the health service is not provided in conformity with the conditions provided by legislation or the contract for financing medical treatment;

4)         the rights of the patient have been violated upon the provision of the health service;

5)         the documents on which assumption of the obligation is based have been prepared incorrectly and the health care provider fails to eliminate the deficiencies within the term agreed upon in the contract for financing medical treatment;

6)         upon provision of the health service, the health care provider violates this Act, other legislation or a contract entered into with the health insurance fund.

(5)        The health insurance fund has the right and a health care provider is required to notify an insured person in writing within one month of the refusal of the health insurance fund to assume a payment obligation and of the reasons therefor. In the event of a violation of the notification obligation, the health care provider shall lose the right to demand payment for the health service from the insured person.

(6)        An insured person has the right to submit the same objections to a claim for payment submitted by a health care provider as the health insurance fund.

 

Division 3

Second Opinion

 

§ 40. Right to second opinion

(1)        The health insurance fund shall assume the obligation of an insured person to pay for a second opinion pursuant to the list of health services of the health insurance fund if the aim of obtaining a second opinion is to ascertain the correctness of a diagnosis, the need and alternatives for or the expected effect of a medicinal product or health service, or the risks relating to the provision of the service.

(2)        An insured person also has the right to obtain a second opinion pursuant to the procedure prescribed in subsection 27 (2) of this Act in a foreign state or from a health care provider located in a foreign state.

(3)        The conditions and procedure for assumption by the health insurance fund of an obligation of an insured person to pay for a second opinion shall be established by a regulation of the Minister of Social Affairs.

 

Division 4

Benefits for Medicinal Products, Supplementary Benefits for Medicinal Products and Benefits for Medical Devices

(20.12.07 entered into force 1.09.08 - RT I 2008, 3, 22)