While the common perception of a medical error is that a surgeon leaves a sponge in the abdominal cavity during surgery, a medical error can also occur when a family doctor fails to order a timely test or prescribes antibiotics for a viral illness.

No one knows exactly how many medical errors occur in Estonia today, as they are not uniformly recorded. While there is a Health Services Quality Commission operating under the Ministry of Social Affairs, fewer than 200 people approach it each year with their concerns.

"Out of those 170 to 180 cases, about 23 or 24 percent involve actual errors. And if we subtract another ten cases that are related to communication, documentation or other issues, the number drops to under 20 percent," said Marika Väli, head of the Medical Errors Commission.

However, even if experts determine that a medical error has occurred, their opinion alone is not enough for compensation. Patients still had to go through the court system to seek compensation. In a few weeks, this process is expected to become easier for patients, as they will no longer need to go to court and the insurance will cover the damage caused.

"Starting from November 1, it will be easier for patients to receive feedback and compensation for serious health damages that were unavoidable and involved a diagnostic or treatment error. Insurance companies will handle these cases," Väli said.

In summary, to ensure compensation for patients in the event of a medical error, all hospitals, clinics and doctors must take out mandatory liability insurance. However, a situation has arisen at the last minute in this long-prepared reform where only one insurance company, PZU, will offer the insurance. BTA and Seesam withdrew at the last moment, with Seesam explaining that it is very difficult to predict what will happen next.

"We considered offering mandatory liability insurance for healthcare providers, but we assessed the risk as too uncertain compared to the potential profitability. Since it's unknown how many and what size claims might arise, pricing this product is very difficult," said Seesam's marketing director Liljan Männiste.

Healthcare professionals view the insurance premiums as too high and attribute this to the monopoly of a single company, but the insurance company PZU disagrees. PZU states that they based their calculations and risk assessments on Finland's experience.

"The claims handled by the medical malpractice commission represent just the tip of the iceberg. We had to forecast the rest. The real picture of how much damage will occur won't become clear even next year, but over the coming years, because liability insurance, by nature, has a long tail," said Argo Argel, PZU Insurance's product manager for liability insurance.

Specifically, a patient can file a claim within three years of becoming aware of a medical error, but no later than ten years after the error was made. Argel believes that Estonians are more likely to seek compensation than Finns because the process for reporting medical errors has been made very simple. At the same time, he hopes that things won't get as extreme as they have in the United States. According to Argel, the number of claims submitted will determine whether it will be possible to lower insurance prices in the future.

Initially, however, all parties – including emergency medical services, family doctors, dentists and hospitals – are complaining about the extremely high insurance premiums. For instance, according to initial estimates, the insurance premium for the North Estonia Medical Center (PERH) could reach as high as half a million euros. The sum is so large that a public procurement process is required. The premium could be even higher, but the hospital opted for a high deductible, meaning they will cover any compensation claims under €50,000 themselves.

"This tender, which we will launch on Monday, has been planned with a €50,000 deductible. There have been very few cases in our hospital that have exceeded this amount. If the cases covered by insurance this year are similar to those from last year, we will end up covering them within the deductible anyway," said Agris Peedu, director of the North Estonia Medical Center.

While mandatory liability insurance represents a significant additional cost for the hospital, Peedu believes it is the right approach, as it exempts a doctor from criminal liability for an error, provided the mistake was documented and the doctor was not under the influence of alcohol or drugs.

Minister of Health Riina Sikkut (SDE) also considers the reform to be essential.

"This is a very important and fundamental change that has been worked on for years, so that patients do not have to go through the courts and responsibility does not fall on the individual healthcare worker. This way, damages can be compensated and improvements can be made in healthcare," Sikkut said.

According to Sikkut, the new system should provide insights into where and what types of errors occur, enabling improvements in medical training, the enforcement of continuing education and changes to procedures to prevent repeated mistakes. While doctors find the proposed insurance premiums too high, the minister holds a different view.

"The fact that the initial offers are high is understandable to some extent. In a system where we are paying out more compensation than under the old court-based system, the insurance premiums naturally have to be higher. The costs that need to be covered are greater. Moreover, without statistical data on patient safety incidents in Estonia, it is very difficult to determine a fair level for insurance premiums," Sikkut explained.

In recent weeks, the idea of delaying the implementation of the law has also been floated, in the hope that more insurance companies might present offers. However, Sikkut does not support a delay, as she believes that gathering accurate statistics for adjusting premiums is only possible after transitioning to the new system.

According to Mart Jesse, head of the Estonian Insurance Association, postponing the law would worsen the situation.

"If it is delayed again, the current service provider may decide that doing business in such a country is too difficult and close their doors for this service," Jesse said.

He emphasized that the state must now make strong efforts to encourage other companies to enter the liability insurance market.

Argo Argel, of PZU, noted that entering the market with a new service requires nearly a year of preparation and delaying the implementation would not create competition.

"Our competitors are closely watching us to see how we fare, and based on that, they will decide whether to enter the market. This decision won't be clear for at least another year," Argel added.

By December 1, around 1,600 healthcare providers must have liability insurance in place. Without it, healthcare facilities risk losing their licenses.

Recent statistics show that complaints related to dental care have been the most frequent. In 2021, there were 42 such complaints, accounting for a quarter of all grievances. In other years, the proportion has been smaller.

Looking at how many of the total complaints were found to have merit by the expert commission, this figure also hovers around a quarter or slightly less. In 2021, there were 42 confirmed cases. These statistics only reflect cases brought to the expert commission and do not include situations where patients resolved issues directly with healthcare providers.

By comparison, Finland's patient insurance system, which has been in place for decades, handled 10,559 decisions on treatment quality last year, with 2,507 cases resulting in compensation for errors. Although Finland is a larger country, the vast difference between Finland's thousands of complaints and Estonia's hundreds suggests that many Estonians have not yet pursued their grievances, likely due to the complexity of claiming damages.

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