Health Insurance Fund submits €1.7 million-worth of recovery claims

Health Insurance Fund (Haigekassa) office.
Health Insurance Fund (Haigekassa) office. Source: Siim Lõvi /ERR

The Health Insurance Fund (Haigekassa) has submitted 2,258 claims of recovery from health institutions and individuals, to the tune of €1,738,465 million, citing fradulent activity.

The head of the fund's claims department, Jelena Kont, said that there are several ways in which the Health Insurance Fund can or has to demand money back, according to the law.

A common fraud employed both against the Health Insurance Fund and the Tax and Customs Board (MTA) involves declaring social tax but not paying it later on.

"This is a situation where a company declares social tax for its employees but doesn't pay it later, to the MTA. At the same time, an employee may be on sick leave and gets compensation from us. When the MTA detects that the social tax has not been paid and corrects the data, we have the right to ask for the money," Kont said.

Meanwhile, there are criminal proceedings taking place where the Health Insurance Fund is included as a victim, since it is not always possible to get the money back through administrative proceedings. "Asking the money back for frauds is also a question of principle, because those people who might need treatment are the ones who suffer from these types of fraud," Kont said.

An employer can't pay salary to people on sick leave. "The Health Insurance Fund pays incapacity benefit to people who at the same time don't receive a wage. The compensation isn't meant for deceiving the state and taxpayers and earn more money. It is illegal," Kont said.

Even though a lot of people may be unaware of this, the Health Insurance Fund also demands the money back when an individual is at fault in injuries to others that require medical treatment.

In 2020, there were 366 such situations, and the claim for recovery stood at €350,000.

Kont said that the average guilty party had to pay around €1,000, but the reality is that the breakdown consisted of a lot of bills of a few dozen euros and then a small number which came to a couple dozen thousand euros.

If the claimed amount is not reimbursed, the Health Insurance Fund will turn to the courts. Last year, the fund submitted 142 applications in the sum of €232,000.

Being guilty of causing a traffic accident can result in a very large claim, in which case the Health Insurance Fund also recovers the costs of treatment of the victims, the costs of medicines and incapacity benefit.

Last year, there were fewer claims than in 2019, but at the same time, the total amount of claims has increased, because health care is constantly becoming more expensive.

In 2019, there were a total of 830 receivables reported, totalling approximately €804,000, and last year 800 receivables, coming to approximately €881,000.

One of the claims that often arises from ignorance is the use of the European Health Insurance Card. People often need medical care during their trip and present a health insurance card to a medical institution in a Member State of the EU without having health insurance in Estonia at the same time. "It is not taken into account that the card can only be used if the person has health insurance in Estonia. The card is only meant for the validity of the insurance. Later, all bills for medical care provided under the health insurance card will reach us," Kont said.

Last year, there were 34 such cases totaling €27,000.

Medical institutions cannot escape recoveries either. Although much of the recovery claims are due to human error, there are also those who bill for services that people have not received. Last year, there were a total of 572 claims for approximately €332,000 submitted to medical institutions.

"We continue to ask people to view their medical bills in a digital history environment. Only the person knows whether he has actually received the services prescribed by the doctor. We received several clues from people last year, we checked them and made recoveries," Kont said.


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Editor: Roberta Vaino

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