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Insurance company to reimburse and cover costs for the medicine OPDIVO

26/03/2020

In January this year, we informed you about our success with an application for extraordinary reimbursement of the medicine OPDIVO (nivolumab) at the Supreme Administrative Court. Our client was an oncological patient whose chemotherapy treatment failed completely, and the only option for him was immunotherapy in the form of the drug OPDIVO.


The Supreme Administrative Court disagreed with the opinion of both the health insurance company and the Municipal Court in Prague, and concluded that the conditions for extraordinary reimbursement under Section 16 of the Public Health Insurance Act were fulfilled in this case as OPDIVO was the only remaining treatment option for the patient. The Supreme Administrative Court overturned the previous decision of the health insurance company and the Municipal Court in Prague, and returned the case to the insurance company for approval of the application.

The problem that arose thereafter was that the client had already paid for the treatment as his health condition was very serious, and it was not possible to wait any longer. However, reimbursement from public health insurance is usually made only after the treatment has been approved, and the insurance company subsequently sends the payment directly to the account of the health service provider, and not to the patient. However, on the basis of our urgency, and thanks to cooperation from the health service provider, the insurance company was able to pay the health service provider for the treatment cost, which was then refunded to the client by the health service provider.