Announcement regarding treatment abroad for the insured person L.I.
The HIFRNM has been closely monitoring the case of L.I. from the first moment, from his hospitalisation in the Republic of Greece, from where he was brought to PHI KARIL, through to the submission of the request for referral for treatment abroad.
At this moment, two separate procedures are being conducted within the Fund.
The first was initiated as early as September 2023 and an open case exists for it, which is still ongoing due to incompletely submitted medical documentation, for which an official request has been sent to the applicants; however, the necessary documentation for a decision has still not been submitted.
Since September 2023, the patient was transferred to PHI KARIL, from where, on the family's own initiative, he was taken by medical vehicle to a private hospital with which the HIFRNM has not concluded an agreement for the type of health services provided, and where he stayed until the moment when, on 6.2.2024, he was transported by helicopter to a health institution in Austria.
The HIFRNM was neither informed nor involved in the organisation of the helicopter transport by which the patient left for a health institution in Austria, on the family's initiative.
With regard to the Decision adopted by the First-Instance Commission of the HIFRNM, it is important to note that it acted on the documentation submitted with the request, as well as on the documentation it additionally obtained ex officio. Namely, the Decision was adopted as a result of the fact that the Proposal for referral abroad itself does not contain any specific direction regarding the type of intervention that needs to be performed during treatment abroad, but contains only general rehabilitation procedures.
In addition, the type of treatment proposed by the centre in Austria relates to health services in the field of physical therapy and medical rehabilitation.
Acting upon the request, the First-Instance Commission of the HIFRNM adopted a negative decision.
Here, once again, we would like to point out the legal limitations in acting on this case, more precisely, pursuant to Article 30 paragraph 1 and paragraph 2 of the Law on Health Insurance (“Official Gazette of the RNM” No. 25/00; 34/00; 96/00; 104/00; 30/01; 48/01; 50/01; 11/02; 31/03; 84/05; 119/05; 37/06; 109/06; 18/07; 36/07; 88/07; 88/07; 106/07; 82/08; 98/08; 142/08; 6/09; 45/09; 67/09; 14/10; 50/10; 156/10; 19/11; 53/11; 166/11; 26/12; 65/12; 145/12; 16/13; 91/13; 187/13; 43/14; 44/14; 97/14; 112/14; 113/14; 188/14; 20/15; 61/15; 61/15; 98/15; 129/15; 150/15; 154/15; 192/15; 217/15; 27/16; 37/16; 120/16; 142/16; 171/17; 275/19; 92/20; 77/21; 285/21; 60/23; 154/23; 209/23):
“The insured person may use hospital treatment abroad with the approval of the Fund, if the matter concerns a disease that cannot be treated in the Republic, and in the country to which the insured person is referred there is a possibility of successful treatment of that disease.
The insured person, under the conditions established in paragraph 1 of this Article, may also use health services abroad 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.”
In addition, pursuant to Article 44 paragraph 3 of the Rulebook on the manner of using health services by insured persons abroad (“Official Gazette of the RNM” No. 234/22), it states:
“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 a diagnostic procedure, a follow-up examination before the performance of hospital treatment, follow-up examinations after completion of hospital treatment for which the insured person has not conducted a procedure before the Fund, for treatment that is not based on adopted medical doctrine and evidence-based medicine, as well as for treatment that is in the phase of a clinical study and specialised medical rehabilitation, shall not be entitled to reimbursement of costs at the expense of the Fund, pursuant to the provisions of this Rulebook.”
According to these legal and by-law provisions, the Fund may refer an insured person only for hospital treatment and a follow-up examination after approved hospital treatment abroad, but not for medical rehabilitation.
In addition, we also wish to emphasise that the Decision of the Fund rejecting the request for referral abroad is still not final.
Upon receipt of the decision, the party is informed of the regular legal avenues that it may use in the administrative procedure conducted by the Fund.
In accordance with the applicable legislation, when using legal remedies the party has the right to submit evidence and additional medical documentation which it considers may affect the procedure, and with which it would challenge the already adopted decision of the Fund.
Respectfully,
HIFRNM