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Our law firm is often times approached by patients who need a costly treatment that is not covered by health insurance. In these cases, patients can ask their health insurance companies to provide the so-called exceptional coverage of treatment under section 16 of the Act on public health insurance.
The exceptional coverage of treatment under section 16 can be provided if three basic conditions are met:
The first condition is that the treatment is not covered by health insurance. Usually, the patient learns about this fact from their attending physician.
The second condition is the “exceptionality” of the patient´s case. The substance of this requirement can differ in different cases. In one of the cases that were heard by a court, the ‘exceptionality’ was seen in the exceptionality of the condition the patient needed the treatment for. The patient´s condition was described by the literature as an “ultra-rare disease”. In a different case, the ‘exceptionality’ was seen in the exceptionally quick progression of the patient´s disease, and the impossibility of a postponement of treatment due to the risk of blindness.
The last condition is that the treatment needs to be the only option for the patient in regard to their medical condition. The fact that this condition is met can be confirmed by an expert opinion of the patient´s attending physician. In their expert opinion, the physician can underline that the exceptional coverage is asked for after and because the previous treatment that is covered by health insurance was not successful or because the treatment its coverage is asked for is expected to have, compared to the previous treatment, a medical benefit for the patient and to improve their medical condition.
The health insurance companies assess the patient´s requests for the exceptional coverage extremely carefully. In general, they tend to base their decisions in a very restrictive interpretation of section 16 of the Act on public health insurance. This approach of the health insurance companies can then be revised by courts. In the past, patients were successful with their lawsuits against health insurance companies in relation to the exceptional coverage of medicines, including Kuvan or Perjeta.
Do you also need treatment that is not covered by health insurance and the health insurance company is rejecting your claim? Do you need to appeal the health insurance company´s decision and do not know how? Are you considering filing a lawsuit against the health insurance company? Get in touch with us, we are happy to help you.
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Jasper Brinkman
Jasper Brinkman
"Following a devastating hotel fire in Prague, the law firm Holubová advokáti, led by attorney Klara Dvorakova, successfully represented our extended family as a group of victims. The firm navigated complex international insurance and compensation laws to defend our rights.
I would like to acknowledge the extraordinary efforts the firm had to make to bring our case to a successful compensation under extremely difficult circumstances."
Stewarts
Stewarts
"A visit to her daughter in London turned Eva's life upside down when she says she stepped into a crossing on a green light but was hit by a car. Despite her remarkable bravery, she faced a long treatment due to fractures in her pelvis, and the associated limitations and pain are likely to persist for the rest of her life. Regular headaches and impaired concentration compound her challenges.
Eva contacted us through an organization temporarily helping her manage her difficult living situation. At that time, she was destitute, relying only on subsistence payments. We were able to assist her because we specialize in personal injury and have contacts with proven colleagues abroad.
We worked with Stewarts, a UK law firm, on this case. Attorneys Klára Dvořáková and Rebecca Huxford helped Eva with the documentation in her case, explaining her options and the differences between the Czech and British systems of healthcare and social benefits reimbursement. Within a few months, thanks to the professional cooperation between the two offices, an offer of compensation from the insurance company of approximately CZK seven million was achieved. The client accepted this settlement because she did not want to deal with courts in the United Kingdom.
Subsequently, we assisted the client with related tax issues and contacted Auditone, a tax consultancy firm, which arranged for the filing of a tax return. Compensation for lost income is taxable, unlike most personal injury compensation.
'No one has done as much for me as you,' Eva said.
The fact that we were able to help Eva gives our work meaning and brings us great joy. We are very happy that, thanks to our many years of active involvement in the international professional organization PEOPIL, we can cooperate on such cases."