Case VII SA/Wa 424/08

Case File No. VII SA/Wa 424/08
Download Judgment: English Polish
Country: Poland
Region: Europe
Year: 2008
Court: The Voivodeship Administrative Court in Warsaw [Wojewódzki Sąd Administracyjny w Warszawie]
Health Topics: Health systems and financing
Tags: Health insurance, Health regulation, Out-of-pocket expenditures, Reimbursement

The plaintiff’s son had a congenital heart defect and sought surgery at University Hospital in M , which was outside of Poland.  The plaintiff applied to the Polish National Health Fund to pay for the treatment. While awaiting the decision of the President of the National Health Fund, the plaintiff had the surgery performed.

As the surgery had been performed before the decision was made, the President of the National Health Fund stopped reviewing the plaintiff’s application, refusing to pay the hospital for the treatment. The President noted that the treatment could have been done in Poland. The Plaintiff brought a complaint against this decision.

The Court dismissed the complaint.  The Court held the relevant acts required the President’s consent for reimbursement and that the procedure to apply for reimbursement of planned medical treatments abroad required the consent prior to treatment.  In the present case, however, the required treatment occurred before the decision of the President of National Health Fund, making it appropriate for the President to dismiss the application. The Court also noted that this view was supposed by European Economic Community law. 

“Such requirement clearly follows from the wording of Art. 25 of the Act of 27 August 2007 on Publicly Funded Healthcare Benefits (Dziennik Ustaw No.210, item 2135 as amended). Pursuant to Art. 25(1) of the Act quoted hereinabove, the National Health Fund shall not finance medical treatment or medical tests abroad of an insured person with the exception of the costs of healthcare benefits to which the insured person is entitled pursuant to the provisions on coordination. (Page 2)

“Nie można podzielić zarzutu skargi, iż "przepis art. 25 ust. 2 ustawy nie wprowadza bezwzględnego wymogu uprzedniej zgody Prezesa Funduszu na przeprowadzenie leczenia". Wymóg taki wynika wyraźnie z brzmienia art. 25 ustawy z dnia 27 sierpnia 2004r o świadczeniach opieki zdrowotnej finansowanych ze środków publicznych (Dz. U. Nr 210, poz. 2135 ze zm.).”

“The regulation referred to hereinabove specifies the procedure for referring patients for planned medical treatment abroad exclusively prior to conducting the treatment.” (page 3)

“Wskazane wyżej rozporządzenie określa procedurę kierowania na planowane leczenie za granicą wyłącznie przed jego przeprowadzeniem."

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