- •§ 1. Scope of application of Act
- •§ 2. Definition, principles and form of health insurance
- •§ 3. Insurer
- •§ 4. Health promotion
- •§ 5. Insured person
- •§ 6. Duration of insurance cover of employees and public servants
- •§ 7. Duration of insurance cover of persons for whom social tax is paid by state or local government
- •§ 8. Duration of insurance cover of members of management or controlling bodies of legal persons
- •§ 9. Duration of insurance cover of persons receiving remuneration or service fees on basis of contract under law of obligations
- •§ 91. Duration of insurance cover of persons receiving unemployment insurance benefit
- •§ 10. Duration of insurance cover of sole proprietors entered in register
- •§ 11. Duration of insurance cover of persons considered equal to insured persons
- •§ 12. Specifications concerning duration of insurance cover of persons considered equal to insured persons
- •§ 13. Submission of documents and information
- •§ 14. Liability of persons obligated to submit documents
- •§ 15. Health insurance database
- •§ 16. Chief processor and authorised processor of health insurance database
- •§ 17. Information to be entered in health insurance database
- •§ 18. Right to collect information
- •§ 19. Entries in health insurance database
- •§ 20. Statutes for maintenance of health insurance database
- •§ 21. Proof of insurance cover
- •§ 22. Persons considered equal to insured persons on basis of contract
- •§ 23. Application of Acts
- •§ 24. Conditions under which person is considered equal to insured persons on basis of contract
- •§ 25. Definition and types of health insurance benefit
- •§ 26. Right of recourse of health insurance fund
- •§ 27. Territorial effect of health insurance benefits
- •16.12.04 Entered into force 1.01.05 - rt I 2004, 89, 614
- •§ 28. Restrictions on receipt of health insurance benefits
- •§ 29. Scope of insurance cover
- •§ 30. List of health services of health insurance fund
- •§ 31. Amendment of list of health services
- •§ 32. Payment to health care providers
- •§ 33. Dental care benefit for insured person under 19 years of age
- •§ 34. Disease prevention
- •§ 35. Contract for financing medical treatment
- •§ 36. Entry into contract for financing medical treatment
- •§ 37. Conditions of contract for financing medical treatment
- •§ 38. Waiting list
- •§ 39. Assumption of obligations
- •§ 40. Right to second opinion
- •§ 41. Scope of insurance cover in case of benefits for medicinal products
- •§ 42. Reference price, price agreement, basic rate of cost-sharing and maximum rate of benefit for medicinal products
- •§ 43. List of medicinal products
- •§ 44. Discount rates for medicinal products
- •§ 45. Entry into price agreement
- •§ 46. Assumption of obligations to pay for the sale of medicinal products
- •§ 47. Supplementary benefit for medicinal products.
- •§ 48. Scope of insurance cover in case of benefits for medical devices
- •§ 481. Amendment of list of medical devices
- •§ 49. Assumption of obligation to pay for medical devices and contracts with sellers
- •§ 50. Definition and types of benefit for temporary incapacity for work
- •§ 51. Insured event of temporary incapacity for work
- •§ 52. Certificate of incapacity for work
- •§ 53. Procedure for grant and payment of benefit for temporary incapacity for work
- •§ 54. Size of benefit for temporary incapacity for work
- •§ 55. Calculation of average income per calendar day
- •§ 56. Right to receive benefit for temporary incapacity for work
- •17.12.08 Entered into force 1.07.09 - rt I 2009, 5, 35
- •§ 57. Period of time serving as basis for calculation of sickness benefit
- •§ 58. Period of time serving as basis for calculation of maternity benefit or adoption benefit
- •§ 59. Period of time serving as basis for calculation of care benefit
- •§ 60. Restriction on right to receive benefit for temporary incapacity for work
- •§ 61. Prohibition on permitting insured person who is temporarily incapacitated for work to assume employment or service
- •§ 62. Rights of health insurance fund upon payment of benefit for temporary incapacity for work
- •§ 63. Adult dental care benefit
- •§ 64. (Repealed - 16.12.04 entered into force 1.01.05 - rt I 2004, 89, 614)
- •§ 65. Documents necessary for receipt of adult dental care benefit
- •§ 66. Connection between adult dental care benefit and specific period of time
- •§ 67. Additional fee and prohibition on extension of additional fee
- •§ 68. Obligation to provide health service in standard conditions of accommodation
- •§ 69. Fee for home visit
- •§ 70. Visit fee and additional cost-sharing upon payment for out-patient specialised medical care
- •§ 72. Maximum rate of visit fee and in-patient fee
- •§ 73. Fee for issue of documents
- •§ 74. Repeal of Republic of Estonia Health Insurance Act
- •§ 75. Amendment of Republic of Estonia Employment Contracts Act
- •§ 76. Amendment of Wages Act
- •§ 77. Amendment of Public Service Act
- •§ 78. Amendment of Medicinal Products Act
- •§ 79. Amendment of Mental Health Act
- •§ 80. Amendment of State Fees Act
- •§ 81. Amendment of Income Tax Act
- •§ 82. Amendment of Estonian Health Insurance Fund Act
- •§ 83. Amendment of Social Tax Act
- •§ 84. Amendment of Holidays Act
- •§ 85. Amendment of State Liability Act
- •§ 86. Amendment of Health Services Organisation Act
- •§ 87. Amendment of Value Added Tax Act
- •§ 88. Calculation of average income per calendar day until entry into force of § 55 of this Act
- •§ 89. Transitional provisions
- •§ 90. Entry into force of Act
§ 26. Right of recourse of health insurance fund
(1) The health insurance fund has the right of recourse against a person who is liable for the occurrence of an insured event due to which an insured person receives health insurance benefits, and against the insurers who are required to provide benefits in connection with that insured event.
(2) The health insurance fund has the right of recourse to the extent of a health insurance benefit paid by the fund pursuant to the procedure provided for in the State Liability Act (RT I 2001, 47, 260; 2002, 62, 377; 2003, 15, 86) in the case of loss caused to an insured person by a public authority through damage to health or a bodily injury.
(3) Based on § 1041 of the Law of Obligations Act, the health insurance fund has the right of recourse concerning persons who use the European health insurance card or the provisional replacement certificate of the European health insurance card after the suspension or termination of their insurance cover to the extent of the health insurance benefit paid by the fund to such persons. (19.06.08 entered into force 1.08.08 - RT I 2008, 34, 210)
§ 27. Territorial effect of health insurance benefits
(1) Except in the cases provided for in subsection (2) of this section and subsection 36 (3) of this Act, insured persons have the right to receive health insurance benefits in kind only in Estonia.
(2) An insured person may receive health service benefits in a foreign state on the basis of a written contract entered into beforehand between the insured person or his or her legal representative and the health insurance fund, unless otherwise provided by an international agreement.
(3) Based on an application by an insured person or his or her lawful representative, the health insurance fund may enter into a contract for the provision of health service benefits to an insured person in a foreign state if:
1) the health service applied for or alternatives to such health service are not provided in Estonia;
2) provision of the health service applied for to the insured person is therapeutically justified;
3) the medical efficacy of the health service applied for has been proved;
4) the average probability of the aim of the health service applied for being achieved is at least 50 per cent.
(19.06.08 entered into force 1.08.08 - RT I 2008, 34, 210)
(31) At least two medical specialists, one of whom shall be the medical specialist providing health service to the insured person, shall assess the conformity of an insured person to the criteria specified in subsection (3) of this section.
(19.06.08 entered into force 1.08.08 - RT I 2008, 34, 210)
(4) Adult dental care benefit shall be paid under the conditions provided for in this Act regardless of the place where the expense is incurred.
16.12.04 Entered into force 1.01.05 - rt I 2004, 89, 614
§ 28. Restrictions on receipt of health insurance benefits
(1) If a person fails to follow the medically justified treatment prescribed by a doctor, he or she shall lose the right to receive health insurance benefits in connection with the case of disease for the prevention of which or against which the particular treatment was prescribed.
(2) In the cases provided for in subsection (1) of this section, the health insurance fund shall decide on the loss of a right to receive health insurance benefits pursuant to the procedure provided for in the Administrative Procedure Act, taking into account the specifications prescribed in this Act.
(3) Challenge proceedings with regard to a decision made by the health insurance fund on the basis of subsection (2) of this section may be initiated by an insured person within ten calendar days pursuant to the procedure provided for in the Administrative Procedure Act.
(4) The provisions of subsection (1) of this section do not apply if:
1) the monetary value of the health insurance benefit concerned does not justify restriction of the insured person’s right to bodily self-determination;
2) application of the provisions would constitute a significant breach of the insured person’s right to bodily self-determination;
3) the insured person or his or her legal representative has good reason for refusing to grant consent to or follow the treatment prescribed by the doctor;
4) the health service prescribed is likely to cause a risk of serious health damage to the insured person or his or her death;
5) the health service prescribed causes great pain or a danger of prolonged pain to the insured person.
(5) An insured person does not have the right to receive a health insurance benefit if the need for the benefit has arisen as a result of participation in scientific research, including a clinical trial.
(6) The right to receive a health insurance benefit expires within three years as of the creation of the right unless otherwise provided by this Act.
Division 2
Health Service Benefit
Subdivision 1
Health Services