The family of a child with leukemia was granted an interim order obligating the Estonian Health Insurance Fund (EHIF) to pay for the child's cancer treatment in Helsinki. While EHIF claims that there is insufficient evidence to support the treatment method being used, the obligation to reimburse this medical care will remain in place until litigation is complete.
On Monday morning, nine year old Kaspar Martin traveled to Helsinki for immunotherapy. According to Ellex Raidla Law Firm attorney Ants Nõmper, who is representing the family in court, this was a last-ditch effort, as if he had gone without this treatment, his life expectancy would have been limited to just a couple of months. Kaspar Martin's treating physician believes that if this treatment is successful, it could give him another two to three years.
"The treatment options available in Estonia — which are actually rather good — have been exhausted, but there are more treatment options out there in the world," Nõmper explained. "The closest treatment option is in Helsinki. The University of Helsinki offers a modern new treatment option that suited this patient. The only barrier was lacking half a million euros."
EHIF, however, refused to cover the child's treatment, prompting his family to take the decision to court. This Monday, the family was granted an interim order. In other words, the court found that EHIF must continue to cover the medical bills for the child's treatment so long as litigation remains underway. It could be a year or two before the case is settled. Moreover, it cannot be ruled out that EHIF may win the case.
"According to the law, in that case, the family will have to repay that money," Nõmper acknowledged. He added, however, that it wouldn't have to be repaid right away, and that a payment plan could be implemented.
He also noted that Monday's interim order does not mean that others in the same situation automatically have the right to be reimbursed by EHIF as well; these cases must be claimed in court individually.
While very expensive treatment cases reduce the amount of funding available for others' treatment, it can't be claimed each time that there's no money for treatment, Nõmper said.
"You have to go to court, and the court will decide whether EHIF has to find money for something or not, as everything is a matter of prioritization," he stressed.
According to Ergo Pallo, director of EHIF's Legal Department, medical treatment abroad is paid for if and when it meets four requirements: the treatment is prescribed for the patient, it isn't offered in Estonia, its efficacy has been proven, and it meets an efficacy threshold of at least 50 percent. While the child's treating physician believes the treatment in question could have an efficacy of up to 70 percent, EHIF data disagrees.
"In this case, EHIF found that two criteria have not been met — namely, evidence of [this treatment's] medical efficacy, and an at least 50 percent likelihood of it working," Pallo said.
While EHIF refused to pay for this treatment, preparations are already underway to introduce it in Estonia.
"In order for that to happen, however, it has to fulfill the same requirements, i.e. we must have the grounds to say that it is evidence-based and actually works," Pallo explained. "Unfortunately, all current data — from a committee advising EHIF as well as a separate study commissioned from the University of Tartu — we don't have the results yet that would allow us to make such a claim."
Each year, EHIF receives approximately 100 applications for treatment abroad, 90 percent of which are approved. Foreign treatment costs the fund nearly €3.5 million a year. Nonetheless, according to Pallo, it would take a significant increase in the number of applications before these treatments began impeding on the accessibility of medical care within Estonia.
Editor: Aili Vahtla