Oversubscription in the lump sum - we can't afford not to pay it

History of "overcontracting"

I remember when I started working in the Office of the Government Plenipotentiary for Health Insurance Funds in 1998.At that time, no one knew the concept of "overcontracting." The term was first coined in 2001.We were then at the stage of changing the health care system from the Health Insurance Funds to a system based on the National Health Insurance Fund.

From 2001 to 2003, I won all the "overcontracting" cases, not realizing that my personal successes were a failure of the system.

The courts, above all the Supreme Court, have taken the position that since the basis for the provision of benefits is a contract, which contains the maximum amount of the payer's obligation to the provider, the deliberate performance of medical procedures in excess of the contractual limit cannot result in a successful claim for payment.

The Supreme Court's position on the issue of pursuing claims for over-limit benefits has changed over time. Back in 2003, there was a ruling announcing a change in this regard, in which the court stated that "the provision of Article 7 of the Law on Health Care Institutionsimposes an obligation on a health care institution to provide health care services if a person reporting to the health care institution needs immediate health care services due to a threat to life or health, and does not regulate the financial consequences of providing health care services. [...] This means, therefore, that if a public health care facility provides a service in a life- or health-threatening situation, the obligation to bearthecost ofthe service to a patient entitled under health insurance will be borne by the health insurance fund to which the patient belonged (currently the National Health Fund)." [1]

Oversubscription in the lump sum - the courts on the side of the National Health Service

"Under the amended law, however, the increased amount of services over the contracted lump sum may find coverage by increasing it in the next billing period, without the obligation to return the portion of this lump sum that is not used, and thus a mechanism has been provided to compensate for the previously spent funds, although it is not perfect and fully satisfactory to medical entities. Therefore, one cannot agree with the applicant's argument that, by entering into a contract with it, the National Health Fund, contrary to the principles of social intercourse, imposed on it the obligation to provide an indefinite an...