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Instant assistance allowance for covering co-payments for medicinal products

20. 11. 2013

The ombudsman dealt with a complaint about the procedure of a labour office which had not awarded an instant assistance allowance for covering co-payments for medicinal products, stating that expenses for medicinal products were already contained in the amount of the living minimum and that they needed to be paid from the subsistence allowance received by the complainant. He arrived at a conclusion that the office had erred because it had failed to substantiate in a sufficient manner its decision not to award the benefit.  

The Act on Assistance in Material Need enumerates necessary one-off expenses for which instant assistance may be provided and thus does not rule out the coverage of co-payments by means of this benefit. In the given case, it cannot be stated without anything further that it is always possible to prescribe a medicinal product not subject to a co-payment because a particular medicinal product is not always suitable for a patient (due to its side effects or interactions with other medications). The provision of Sec. 16 of the Public Health Insurance Act cannot be applied either; it enables an insurance company to cover in exceptional cases healthcare not otherwise covered if its provision is the only option of treatment with respect to the state of health of the insured person since in such cases an insurance company covers healthcare services that are not covered at all (and not services covered partly). 

If the statements of the attending doctor, requested by the labour office, showed that the complainant could not be prescribed medicinal products fully covered by the health insurance company, the labour office should have taken into consideration what amount of money the complainant was spending monthly on co-payments for medicinal products and whether it was possible for him to pay for them from the subsistence allowance (the complainant received an allowance of about CZK 3,400) besides paying for food, hygienic articles, clothing etc. If, after paying for co-payments for medicinal products, the complainant was not left with necessary funds to buy food and to pay for other basic living needs, extraordinary instant assistance should have been provided to him.

Proper substantiation of a decision is essential not only for applicants (so that they understand the reasons for refusal) but also for the procedure of an appellate body. Decisions insufficient in this respect become unreviewable, which is the reason for their subsequent cancellation. Special attention needs to be paid to the substantiation of a decision if an administrative body uses administrative discretion or the interpretation of a vague legal term, so as to prevent the breach of the prohibition of arbitrariness in decision-making of an administrative body.

In the case in question the labour office had to interpret the vague legal term "necessary one-off expense" and subsequently consider, based on its administrative authority, whether grounds were given (with respect to the income and the overall social and property situation of the complainant) for providing an allowance to cover such expense. It should have given due attention to both these procedures in the substantiation of the decision.

The Ombudsman has long disagreed with the simple line of reasoning that extraordinary instant assistance cannot be provided for covering co-payments for medicinal products and that medicinal products should be paid for from a subsistence allowance. In his opinion, such line of reasoning cannot be adopted, without anything further, because in specific cases the affected person does not have to have sufficient funds for food and other necessary living needs after having paid for co-payments for medicinal products.    

Last quarter, the matter was discussed at a meeting with the representatives of the Ministry of Labour and Social Affairs, the Ministry of Health, Všeobecná zdravotní pojišťovna and the State Institute for Drug Control. At the meeting the ombudsman expressed his belief, along with the representatives of all the institutions addressed except the Ministry of Labour and Social Affairs, that the situation of persons in material need who do not have sufficient funds for necessary co-payments for medicinal products is solvable in individual cases by means of an extraordinary instant assistance benefit. The Ministry of Labour and Social Affairs, however, rejected such position and provides methodological guidance to the Labour Office of the Czech Republic requiring it (regardless of the financial situation of the client), after necessary co-payments for medicinal products are covered, not to provide extraordinary immediate assistance to a client. This can have a material impact on the situation of the client in some cases since the client is de facto forced to choose between paying for necessary medicinal products and basic food. In the previous period the ombudsman also discussed with the Ministry of Labour and Social Affairs the provision of extraordinary instant assistance for covering the expenses of travelling to a healthcare facility by means of public transport. In this case, the Ministry agreed with the ombudsman’s proposals and will provide the benefit to clients in justified cases.

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