Right To Treatment

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Right To Treatment
Right To Treatment

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Right to treatment

Around 98 percent of the people living in Austria are protected by health insurance thanks to the compulsory statutory insurance. Under certain conditions, the health insurance companies assume the costs of health services for their insured persons, with deductibles or contributions to the costs. The health insurance companies provide so-called mandatory and voluntary benefits. The health insurance companies are legally obliged to provide the compulsory benefits, and patients have an enforceable legal claim. This means that a compulsory benefit can also be sued if the health insurance company refuses to provide it in part or in full. Voluntary services are, for example, spa treatments or convalescence stays; there is no legal entitlement to them.

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  • Compulsory health insurance benefits
  • Approval of drugs requiring a head physician
  • Actionable decision

Compulsory health insurance benefits

The compulsory health insurance benefits include:

  • Medical treatment,
  • Hospital care,
  • Sick pay and maternity allowance,
  • Childcare allowance,
  • Jaw regulation, dental treatment and dentures,
  • Medical aids and aids or
  • Travel, travel and transport costs.

According to the General Social Insurance Act (Section 133 ASVG), medical treatment must be “sufficient and appropriate, but it must not exceed what is necessary”. For medical treatment measures, the health insurance companies have defined certain conditions under which the costs of the service are covered. This takes into account the therapeutic effect and benefit of a particular treatment. Doctors must observe these regulations when prescribing treatment. A doctor's approval is often required for certain medical measures (e.g. complex examinations, expensive medication). In certain cases, the attending physician must explain to the chief medical officer of the health insurance company thatwhy a particular examination or treatment is necessary.

Approval of drugs requiring a head physician

Doctors in private practice use a special directory, the so-called Reimbursement Code (EKO), to prescribe medication. This includes all drugs that are approved and available in Austria and that are paid for by the health insurance company. Most drugs are over-the-counter. For medication requiring a head physician, approval must be obtained in advance from the head and medical check-up service of the health insurance company. Doctors can use the Social Security Pharmaceutical Approval Service (ABS) for this purpose. The doctor must explain to the health insurance company in each individual case why the medication that is subject to a head physician's obligation was prescribed. For more information, see The Recipe.

Note Information about drugs (eg prices, active ingredients, pack sizes, instructions for use) can be found under Services drug search using the tools "Reimbursement Code" and "Medicinal Specialties Register".

Actionable decision

If a drug or other mandatory service is rejected by the health insurance company, the patient can apply to the health insurance company to issue a notification. An informal letter with the date and signature of the patient, stating the refused service, is sufficient. The health insurance company must justify the rejection in a notification within two weeks. You can take legal action against this decision at the responsible labor and social court or at the regional courts free of charge.

Additional Information:

Advice and information on this subject can be obtained from the patient advocacy office (however, representation in front of the courts is not possible) and the chambers of labor (represented in certain cases in court on matters relating to social security law).

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