Reimbursement of costs for used healthcare
Healthcare used in an emergency
What is emergency medical care
Providing diagnostic and therapeutic procedures that are necessary to eliminate the immediate danger to life and health. It is realized, as a rule, without a referral in healthcare facilities that have concluded a contract with the Croatian Health Insurance Fund for the activity of emergency medicine, emergency services of a hospital healthcare facility, or with the nearest medical doctor. If the insured person used healthcare in a medical emergency, they are entitled to reimbursement of paid costs even if they used healthcare in a healthcare facility or a private practice of a healthcare practitioner in the Republic of Croatia with whom the Fund did not conclude a contract for the provision of healthcare.Request for reimbursement of costs
It is submitted in writing to the regional office, i.e. the competent regional office of the Fund, in accordance with the place of residence or temporary residence of the insured person.The basis for cost reimbursement
Finding, opinion and assessment of the Medical Committee of the Fund in which it is determined that it is a case of healthcare from the mandatory health insurance provided in an emergency.Amount of the approved reimbursement
Up to a maximum of the value of the health standard determined by the Mandatory Health Insurance Act, or general acts of the Fund.Unjustifiably charged health service
Entitlement to reimbursement of costs
The insured person is entitled to reimbursement of the costs of used healthcare if the contracting entity of the Fund unjustifiably:- charged the insured person for healthcare
- refused to provide healthcare imposing as a prerequisite for it the prior purchase of implantable materials, i.e. consumables or medicines from the Basic List of Medicines or, at the discretion of the insured person, medicines from the Supplementary List of Medicines for which the insured person meets the conditions prescribed by general acts of the Fund
- refused to prescribe the medicine from the Basic List of Medicines or, at the discretion of the insured person, medicines from the Supplementary List of Medicines for which the insured person meets the conditions prescribed by the general acts of the Fund
- charged the insured person in full or in part for an approved orthopaedic or other appliance
- instructed the insured person to use healthcare, which they contracted with the Fund, at a non-contractual healthcare facility, or with a non-contractual healthcare practitioner in a private practice, which healthcare was medically indicated for the insured person.
Request for reimbursement of costs
It is submitted in writing to the regional office, i.e. the competent regional office of the Fund, in accordance with the place of residence or temporary residence of the insured person. The request is accompanied by:- medical documentation
- the original of the personal invoice for the paid healthcare service, or the original of the invoice for the paid medicine, implantable or consumable material, and the orthopaedic or other appliance in the name of the insured person
- all relevant facts were established from which it undoubtedly follows that in the specific case there was a breach of contractual obligations by the contracting entity of the Fund, and
- finding, opinion and assessment of the Medical Committee of the Fund in which it is determined that it is a case of use of healthcare that is medically indicated for the insured person and to which they are entitled in accordance with the Mandatory Health Insurance Act and general acts of the Fund.
The insured person is not entitled to reimbursement of the costs of performed healthcare at the expense of the mandatory health insurance if:
- they used healthcare at a non-contractual healthcare facility or at a non-contractual private practice
- they used healthcare in the territory of the Republic of Croatia with contracting entities of the Fund outside the conditions and methods prescribed by the Mandatory Health Insurance Act and general acts of the Fund (without referral)
- they used healthcare abroad outside the conditions and methods prescribed by the Act and general acts of the Fund
- they procured an orthopaedic or other appliance from a non-contractual supplier or from abroad, or from a contracting entity, but without the prior approval of the Fund and verification of the appliance certificate by the Fund
- they purchased a medicine that is not determined by the Basic List of Medicines and the Supplementary List of Medicines.
- In these cases, the insured person is obliged to bear the costs incurred in full.