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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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Martin Herna
Martin Herna
"I would like to take this opportunity to express my sincere gratitude to the law firm Holubová advokáti s.r.o. for their professional yet genuinely compassionate approach in an exceptionally difficult period of my life.
The firm successfully represented me in a dispute with my health insurance company concerning reimbursement for a medication that enables me to actively fight an oncological illness and has already begun to show positive treatment results.
From the very outset, I felt a high level of expertise, thoroughness, and a genuine interest not only in the case itself but also in the person behind it. All legal steps were explained clearly and comprehensibly, and the communication was factual, calm, and supported by clear arguments. In a time of great uncertainty, this provided me with a much-needed sense of reassurance and trust.
My special and greatest thanks go to JUDr. Klára Dvořáková, whose commitment, precision, and empathy meant more to me than can be conveyed in just a few sentences. Her work was not only highly professional but also marked by human sensitivity and deep respect for the seriousness of the situation.
I can wholeheartedly recommend this law firm to anyone seeking top-tier legal assistance combined with a truly human approach."
Dietmar Repka
Dietmar Repka
"We express our recommendations for the law firm Holubova Advokati.
Holubova Advokati was able to resolve a project for us with confidence, composure, and perseverance that German experts had deemed hopeless.
About 80 years ago, my grandparents and my father had to leave their home. The property has now been returned to our family through the inheritance that was initiated, and thanks to the excellent work of the law firm.
During the two-and-a-half-year negotiations, there were no language problems; everyone was always well informed about the current status.
Keep up the good work, everyone."