Announcement regarding the request for referral for treatment abroad for the insured person L.I.

Decisions on the exercise of rights under compulsory health insurance for insured persons are adopted by the Health Insurance Fund of the Republic of North Macedonia in accordance with legal regulations and rulebooks.
 
The request of the insured person B.I. from Skopje, for his child L.I., for referral for treatment abroad, was rejected as unfounded, because it is not a matter of referral for treatment abroad but of performing the health service medical rehabilitation, as extended hospital treatment. 
Medical rehabilitation, as extended hospital treatment, is provided by the Fund in health institutions in the Republic of North Macedonia with which it has concluded an agreement, and it may be used by all insured persons of the Fund.

According to the Law on Health Insurance, an insured person may use hospital treatment abroad with the approval of the Fund only if the matter concerns a disease that cannot be treated in the country, and the possibility of successful treatment of that disease exists in the country to which the insured person is referred. 
Under the same conditions, health services are also used for follow-up examinations relating to already performed hospital treatment abroad, approved by the Fund, which cannot be performed in the Republic of North Macedonia.

According to provisions of the Rulebook on the manner of using hospital treatment for insured persons abroad, an insured person to whom the clinical council of the relevant University Clinic in Skopje has issued a proposal for referral for treatment abroad, for the purpose of carrying out specialised medical rehabilitation, as is the case here, is not entitled to reimbursement of costs at the expense of the Fund. 
In view of all this, the decision for the insured person L.I. was adopted by the Fund and the medical commissions in accordance with the above-mentioned legal regulations. 

Respectfully,
HIFRNM