The decision of the insurance company cannot override five medical reports, said the lawyer representing the family of little Martin

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Events, comments: Reimbursement of extraordinary health services (source: ČT24)

Attorney Zdeněk Joukl, representing the Martínek family, who suffers from a rare genetic disorder, wants to open a societal discussion about serious and rare diseases and their compensation from insurance companies. According to him, the time aspect of decision-making is especially important. The role of the doctors involved in submitting the application is significant. However, some of them are underfunded, said Barbora Dubanská, a lawyer specializing in pharmaceutical law, in the program Events, comments.

“We feel that the health system is well set up, but it needs to be fine-tuned,” Joukl said. Martínek’s request for treatment was rejected by the insurance company, but the family will appeal against that decision, even though the treatment has already taken place, explained Joukl.

Dubanská also supported his statement. “The system is relatively well set up, but it’s about the details,” she said. This is the so-called extraordinary reimbursement of health services according to section number 16 of the Act on Public Health.

“I am very happy that we have this tool, where we can get hold of a preparation that would not normally be covered. However, it is a question of how long it takes and who decides,” she added. Every patient does not know about this option or will not be able to obtain funds for treatment through it.

In this context, Joukl mentioned the position of coordinator. According to the lawyer, there is a need for a person or an organization that parents or patients could turn to and that would comprehensively help them manage a difficult situation when they learn of an unexpected diagnosis.

Timely processing of the request

According to Dubanská, the Martínek case turned the problem of rare diseases into a societal issue. “When society sees a small child, it’s a bigger issue for all of us,” said the lawyer. According to her, however, it remains important that requests for extraordinary reimbursement are assessed from a medical point of view.

“There is a significant role here for the doctors who help with the application and the review doctors,” she added. According to her, an improvement could be that the application on the part of the insurance companies is not assessed by a single doctor, but that it is a joint consortium decision-making of well-paid doctors.

Dubanská drew attention to the fact that, at the moment, reviewing doctors are poorly paid, and therefore there are few of them, which leads to the fact that the processing of requests for extraordinary payment of health services is lengthy.

Financing treatment

Joukl supported the idea of ​​processing the request in time and related the issue of financing to the case of Martínek. “We respect the insurance company’s legal opinion, but you can’t have four to five medical reports or expert results on one side and, on the other hand, have one conclusion from the reviewing doctors that the treatment is not beneficial. We wanted to consult about it, we offered to inspect Martínek, but everything was rejected,” the lawyer emphasized.

However, Dubanská pointed to the limited budget of insurance companies. “We have an entire health insurance of almost 480 billion crowns a year, which we have to divide among all of us,” she said. According to her, the way is to measure the effectiveness of the resources spent.

In conclusion, Joukl promised that if the Martínek family manages to get the money from the insurance company as well, it will be distributed “in a very transparent way”, just like the current surplus from the collection.

“We already have the first stories we’re selecting,” he said, noting that one story Martínek’s family has already decided to support. “She is a little girl who is to undergo an operation in Vienna. We spoke with the family on Thursday and they were very happy. It was the news of the year for them, as well as for Martínek,” he said.

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