M.V. to the Supreme Court

U.No. 533/02
Download Judgment: English Macedonian

The Plaintiff, on behalf of his child, requested full reimbursement for the child’s treatment in Croatia. The Plaintiff had received authorization from the Health Insurance Fund for reimbursement of travel and medical costs for up to 30 days of treatment in the facility in Croatia. He then sought a further 35 days treatment, which was rejected by a first-instance administrative authority.

The authorities explained that the additional 35 days of treatment were unnecessary, because the child could receive the same care at a health facility in Macedonia. The Plaintiff requested reimbursement again from the first-instance authority, this time successfully obtaining 168.819 Denars reimbursement under a rule that allowed for the discretionary reimbursement of medical costs up to the amount that it would have cost locally, but not travel costs or the difference between prices abroad and in Macedonia. A second-instance authority increased this amount to 287.667 Denars due to some irregularities in calculation. The Plaintiff further appealed to the Supreme Court, seeking the full costs of the treatment under a provision that allowed for full reimbursement if proposed by the hospital. The hospital had not submitted a formal proposal, but had written a letter stating that the child was too ill to be transferred to Macedonia and should remain at the Croatian hospital until the child’s condition stabilized.

The Supreme Court declared that the second-instance judgment was correct, and that the authorities had acted lawfully. The Rulebook allowed full reimbursement if prior approval was sought, or if the foreign hospital proposed an extension of the reimbursement period. If no resolution was sought and the hospital did not propose an extension, the Rulebook allowed partial reimbursement, but not reimbursement of travel costs or the additional cost of medical expenses abroad. In this case, the hospital had not proposed an extension of the reimbursement period, but had only notified the authority that the child was too ill to be transferred to a hospital in Macedonia. The procedural requirements for full reimbursement under law had not been fulfilled, so the Plaintiff was legally entitled only to the partial reimbursement.

“If no proposal is made by a foreign Health organization or institution, for continuation of the treatment of the insured person abroad, he is not entitled to a right to compensation for the difference in the cost of the hospital expenses.” Sentence, translation page 1.

“During the decision making, the Court took into consideration the allegations in the lawsuit, which invoke the written notification by the Clinical Center “R” – Z - R.C from 23.09.1997, where it states that the ill party was not in a condition to travel and needed to continue with further treatment according to the indications while the condition stabilized, however taking into consideration that an extension of the approved treatment abroad was not requested by the foreign health care facility and no resolution was delivered on this account, and no procedure is initiated, according to the Court, these allegations are unfounded and cannot be of influence in delivering a different decision.” Translation page 3.