Exceptional coverage of treatment under section 16 of the Act on public health insurance

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.