Source: https://www.global-regulation.com/law/estonia/8250337/health-insurance-act.html
Timestamp: 2020-04-03 22:55:07
Document Index: 129098675

Matched Legal Cases: ['art 01', 'art 01', 'art 19', 'art 01', 'art 01', '§ 57', 'art 01', 'art 01', 'art 01', 'art 01', 'art 01', 'art 01', 'art 01', '§ 9', '§ 8', '§ 47']

Health Insurance Act (Estonia)
RT I 2004, 37, 253
01.05.2004, in part 01.08.2004
RT I 2004, 49, 342
RT I 2004, 56, 400
01.08.2004, in part 01.01.2005 and 01.04.2005
RT I 2004, 89, 604
RT I 2004, 89, 614
RT I 2005, 57, 451
RT I 2005, 71, 546
01.01.2006, 01.04.2006
RT I 2007, 71, 437
RT I 2008, 34, 210
RT I 2008, 56, 313
RT I 2008, 58, 327
RT I 2008, 60, 331
RT I 2009, 29, 176
01.04.2010, in part 19.06.2009 and 01.07.2009
01.01.2010, in part 01.04.2010
RT I 2009, 67, 461
18.04.2010, in part 01.07.2010
01.01.2011, will enter into force on the date specified in the decision of the Council of the European Union regarding the abrogation of the derogation established in favour of the Republic of Estonia on the ground provided for in Article 140(2) of the Treaty on the Functioning of the European Union, Decision No. 2010/416/EU of the Council of the European Union of 13 July 2010 (OJ L 196, 28.07.2010, pp. 24 26).
RT I, 17.02.2011, 1
RT I, 10.06.2011, 7
07.06.2011, the words “or insured persons who are at least 65 years of age” in subsection (6) of § 57 of the Health Insurance Act are declared unconstitutional and repealed by a judgment of the Supreme Court en banc.
RT I, 05.07.2012, 14
RT I, 25.10.2012, 1
RT I, 31.12.2012, 6
01.09.2013, in part 01.01.2014
RT I, 29.11.2013, 1
RT I, 10.01.2014, 2
20.01.2014, in part 01.01.2015
RT I, 16.04.2014, 4
RT I, 16.04.2014, 3
RT I, 08.10.2014, 1
18.10.2014, in part 01.01.2015
RT I, 05.12.2014, 2
01.01.2016, in part 01.01.2015 and 01.07.2016; date of entry into force partially amended to 01.07.2016 and 01.01.2017 [RT I, 17.12.2015, 1]
RT I, 11.03.2015, 2
21.03.2015, in part 01.07.2015 and 01.01.2016
20.12.2015, in part 01.01.2016 and 01.07.2016
09.01.2016, in part 01.01.2016 and 01.03.2016
RT I, 06.04.2016, 1
RT I, 04.05.2016, 1
(1) For the purposes of this Act, an insured person is a permanent resident of Estonia or a person residing in Estonia on the basis of a temporary residence permit or the right of residence or a person legally staying and working in Estonia based on a temporary ground for stay for whom a payer of social tax must pay social tax or who pays social tax for themselves in accordance with the procedure, in the amounts and within the time limits provided for in the Social Tax Act, or a person considered equal to such persons on the basis of this Act or on the basis of a contract specified in subsections 22 (1) and (2) of this Act.
4) members of the management or controlling bodies of legal persons within the meaning of § 9 of the Income Tax Act for whom the legal person or legal persons pay social tax on the basis of clause 9 (1) 2) of the Social Tax Act in the monthly total amount calculated on the basis of at least the monthly rate established in the state budget for the given budgetary year (hereinafter minimum social tax obligation);
[RT I, 11.03.2015, 2 – entry into force 01.01.2016]
5) persons receiving remuneration or service fees on the basis of a contract for services, a mandate or another contract or other contracts under the law of obligations for the provision of services, who are not entered in the commercial register as self-employed persons and for whom the other party to the contract pays social tax on the basis of clause 9 (1) 2) of the Social Tax Act in the monthly total amount calculated on the basis of at least to the extent of the minimum social tax obligation;
31) persons who have been found to have partial work ability or no work ability under the Work Ability Allowance Act;
[RT I, 13.12.2014, 1 – entry into force 01.07.2016 (entry into force amended – RT I, 17.12.2015, 1)]
5) persons acquiring basic or general secondary education, persons acquiring formal vocational education and higher education students who are permanent residents of Estonia and study in an educational institution in Estonia founded and operating on the basis of legislation or in an equivalent educational institution abroad, except for doctoral candidates that receive the doctoral allowance.
[RT I, 05.12.2014, 2 – entry into force 01.09.2015]
§ 8. Duration of insurance cover of members of management or controlling bodies of legal persons and persons receiving remuneration and service fees based on contract under law of obligations
(1) The insurance cover of a person specified in clauses 5 (2) 4) and 5) of this Act will commence as of the making of an entry to the health insurance database if social tax has been declared for the person to the extent of the minimum social tax obligation based on clause 9 (1) 4) of the Social Tax Act. The health insurance fund will make an entry on the day following the day of receiving data on the declaration of social tax for the person from the Tax and Customs Board.
(2) The Tax and Customs Board will immediately submit to the health insurance fund data on persons for whom social tax has been declared to the extent of the minimum social tax obligation in one month.
(3) The insurance cover of the insured person will be suspended on the day following the day when, according to the data received from the Tax and Customs Board, social tax has not been declared to the extent of the minimum social tax obligation by the due date specified in clause 9 (1) 4) of the Social Tax Act.
(4) The insurance cover suspended on the basis of subsection (3) of this section will commence on the next day following the receipt of data from the Tax and Customs Board, which certifies the fulfilment of the minimum social tax obligation.
(5) Subsection (3) of this section does not apply in the period during which the insured person is entitled to the benefit for temporary incapacity for work.
[Repealed – RT I, 11.03.2015, 2 – entry into force 01.01.2016]
(1) The insurance cover of a person specified in subsection 5 (3) of this Act will commence upon expiry of a waiting period of fourteen days calculated as of the entry on the commercial register or the register of taxable persons. The documents necessary for the person to be entered in the health insurance database must be submitted to the health insurance fund by the registrar of the central database of the registration department of Tartu County Court or by the Tax and Customs Board within seven calendar days after the entry in the commercial register or the register of taxable persons.
(3) The insurance cover of a person specified in subsection 5 (3) of this Act will terminate two months after making of the deletion entry in the commercial register or register of taxable persons. The registrar of the central database of the registration department of Tartu County Court or the Tax and Customs Board must inform the health insurance fund of the termination of the activities of a person specified in subsection 5 (3) of this Act within ten calendar days after making the deletion entry.
(4) The insurance cover will be suspended two months after the entry in the commercial register or register of taxable persons of the suspension of the activities, including seasonal activities of a person specified in subsection 5 (3) of this Act. The registrar of the central database of the registration department of Tartu County Court or the Tax and Customs Board are required to inform the health insurance fund of the termination of the operation of an enterprise or the professional activities of a person within ten calendar days after making the entry on suspension of activities in the commercial register or register of taxable persons.
(5) If a person recommences business activities after their suspension, the registrar of the central database of the registration department of Tartu County Court and the Tax and Customs Board must submit to the health insurance fund the details of recommencement of business activities within ten calendar days. Upon receipt of the data, the insurance cover will continue without a waiting period.
(21) The Estonian Unemployment Insurance Fund is required to submit the documents necessary for entering a person specified in clause 5 (4) 31) of this Act into the health insurance database.
(5) The submitter of the documents specified in subsections (2) to (3) of this section is required to notify the health insurance fund of the termination of the insurance cover of a person specified in clause 5 (4) 3), 31) and 5) of this Act within ten calendar days.
(1) The insurance cover of a person who has been declared permanently incapacitated for work or as having partial work ability or no work ability will terminate upon expiry of a term of three months from the expiry of the period of the permanent incapacity for work or partial work ability or absent work ability.
(2) The insurance cover of a person specified in clause 5 (4) 5) of this Act will terminate three months after their graduation from the educational institution.
(11) A person providing a person specified in clauses 5 (2) 1) and 2) of this Act with work must submit the information specified in these provisions, which serves as the basis for the commencement, suspension and termination of the person’s insurance cover on the grounds and in accordance with the procedure provided for in the Taxation Act to the employment register and the latter will forward it to the health insurance fund.
(11) The entries of commencement, suspension and termination of the insurance cover of the persons specified in clauses 5 (2) 1) and 2) of this Act are made on the basis of the data of the employment register.
(1) A person entered in the health insurance database presents their identity document in order to prove their insurance cover in Estonia. In order to prove their insurance cover in another Member State of the European Union, a state of the European Economic Area and Switzerland, a person entered in the health insurance database presents their European health insurance card or provisional replacement certificate of their European health insurance card (hereinafter provisional replacement certificate).
(2) In order to prove their insurance cover, a person under 15 years of age who is entered in the health insurance database may present, instead of the identity document, the European health insurance card or the health insurance card until the issue of the European health insurance card.
(3) The conditions of and procedure for issuing European health insurance cards and provisional replacement certificates will be established by a regulation of the minister responsible for the field.
11) persons who have paid social tax for themselves or for whom social tax has been paid in the calendar year preceding the conclusion of the social tax contract on at least the twelvefold monthly amount established for the budgetary year in the state budget on the ground set out in clause 5 (2) 1), 2), 4) or 5) or subsection 5 (3) or (31) of this Act, or
[RT I, 11.03.2015, 2 – entry into force 21.03.2015]
(4) [Repealed – RT I, 11.03.2015, 2 – entry into force 01.01.2016]
(5) [Repealed – RT I, 11.03.2015, 2 – entry into force 01.01.2016]
(6) [Repealed – RT I, 11.03.2015, 2 – entry into force 01.01.2016]
(2) The health insurance fund will assume an obligation to pay for a medicinal product only if the prescription issued for the medicinal product is in compliance with the conditions and form established by a regulation of the minister responsible for the field on the basis of the Medicinal Products Act. Family doctors operating on the basis of the practice lists of the family doctors and nurses working together with such family doctors, licensed medical specialists, licensed dentists, licensed midwives, doctors (except in events of provision of emergency medical care), dentists and midwives working for a health care provider holding an activity licence for providing specialised medical care, and doctors and dentists registered with the Health Care Board and employed in the Defence Forces have the right to issue prescriptions. As of the third year of residency, doctors-residents have the right to issue prescriptions equal to that of doctors who have acquired the respective speciality of specialised medical care.
[RT I, 30.12.2015, 2 – entry into force 01.03.2016]
(2) A list of the diseases in the case of which a medicinal product intended for the treatment or alleviation of the disease is, upon the existence of a valid reference price or price agreement, subject to entry in the list of medicinal products with a 75 per cent reimbursement rate will be established by a regulation of the Government of the Republic on the proposal of the minister responsible for the field. Upon sale of medicinal products entered in the list of medicinal products with a reimbursement rate of 75 per cent, the 90 per cent reimbursement rate applies to children between 4 and 16 years of age and persons receiving a pension for incapacity for work or an old-age pension on the basis of the State Pension Insurance Act or who have been identified to have partial work ability or no work ability under the Work Ability Allowance Act and insured persons over 63 years of age.
(1) The health insurance fund will additionally compensate for justified and certified amounts starting from 300 euros which were paid during the calendar year for medicinal products entered in the list of medicinal products and necessary for the out-patient treatment of an insured person (hereinafter supplementary benefit for medicinal products).
[RT I, 13.12.2014, 1 – entry into force 01.01.2015]
(4) If an amount calculated in accordance with subsection (3) of this section is 300 to 500 euros, the health insurance fund will compensate 50 per cent of the portion exceeding 300 euros.
(5) If an amount calculated in accordance with subsection (3) of this section exceeds 500 euros, the health insurance fund will, in addition to the amount calculated in accordance with subsection (4) of this section, compensate 90 per cent of the portion exceeding 500 euros.
(6) [Repealed – RT I, 13.12.2014, 1 – entry into force 01.01.2015]
4) the refusal of the insured person from work on the basis of subsection 18 (2) of the Employment Contracts Act or the temporary release of the insured person from the performance of service duties on the basis of subsection 48 (2) of the Public Service Act;
5) the removal of an organ or blood stem cells from the insured person in order to transfer the organ or the cells to another person for treatment purposes whereby the treating doctor has diagnosed that the person is temporarily unable to work in their position or continue to perform their duties or their economic or professional activity due to such removal.
(4) The care benefit is paid to an insured person in respect of the following insured events:
1) nursing a child of under 12 years of age;
3) caring for a child of under three years of age or for a disabled child of under 16 years of age when the person caring for the child is themselves ill or is receiving obstetrical care.
(51) If the insured person submits to the employer or the self-employed person a certificate of incapacity for work on paper, the employer or the self-employed person will make their entries in the respective electronic certificate of incapacity for work of the insured person via the X-road interface within seven calendar days after the date of receipt of the paper certificate from the insured person.
[RT I, 08.10.2014, 1 – entry into force 01.01.2015]
(52) If the insured person submits to the employer or the self-employed person the paper certificate issued by a doctor or dentist who treated the person abroad (hereinafter certificate), the employer or the self-employed person will, within seven days after the date if receipt of the certificate from the insured person, submit to the health insurance fund the certificate and other documents required for granting and payment of the benefit.
(53) The insured person may submit to the health insurance fund the certificate and other documents necessary for the granting and payment of the benefit themselves.
(54) The benefit will be granted and paid on the basis of the certificate if:
1) the insured person’s certificate along with other documents required for granting and paying the benefit has been submitted to the health insurance fund not later than by the 90th calendar days following the date of commencement of the employment or service duties or resuming the economic or professional activities, or
2) the insured person’s certificate along with other documents required for granting and paying the benefit has been submitted to the health insurance fund not later than by the 90th calendar days following the date of resuming participation in the activities of the undertaking of the self-employed person.
(55) The benefit will not be granted or paid if the certificate was not submitted within the time limit provided for in subsection 54 of this section.
(6) The health insurance fund will pay the benefit for temporary incapacity for work within 30 calendar days following the date when the employer of the insured person or the self-employed person has made the required entries in the electronic certificate of incapacity for work or if, in the event of the certificate, the properly compiled documents have reached the health insurance fund. In the event of a delay in payment, the health insurance fund must pay a fine for delay in accordance with law.
11) 80 per cent in the event of taking care of a child of under three years of age or of a disabled child of under 16 years of age if the person providing care is ill or being provided with childbirth assistance, is taking care of an ill family member at home or if a child of under 12 years of age is treated in a hospital or at home;
7) 100 per cent in the event of preventing a criminal offence, protecting national or public interests or saving a human life;
8) 100 per cent in the event of the removal of an organ or blood stem cells in order to transfer the organ or cells to another person for treatment purposes.
(1) Average income per calendar day is calculated on the basis of the information concerning social tax calculated or paid to the insured person, as submitted by the Tax and Customs Board, and the information certifying the right to receive the benefit as submitted by the persons specified in clauses 5 (2) 1), 2), 4) or 5) and subsections 5 (3) and (31) of this Act. Social tax paid by the state, rural municipality, city or artistic association under clauses 6 (1) 1) to 3) and 6) to 14) and subsections (11) and (12) of the same section of the Social Tax Act is not taken into account upon calculating the average income per calendar day.
(14) If the sickness benefit is paid on the basis of clause 54 (1) 8) of this Act, the right to receive the benefit will arise as of the first day of release from performance of the employment or service duties or from engaging in economic or professional activities specified in the certificate of incapacity for work in the event of occurrence of an insured event specified in clause 51 (1) 5) of this Act
(1) In the event of a disease or injury, an insured person has the right to receive sickness benefit until the date on which their work ability is restored as specified in the certificate for sick leave, but not for more than 240 consecutive calendar days in the event of tuberculosis or 182 consecutive calendar days in the event of any other disease.
(2) [Repealed – RT I, 13.12.2014, 1 – entry into force 01.07.2016 (entry into force amended – RT I, 17.12.2015, 1)](3) In the event of quarantine, the insured person has the right to receive the sickness benefit until the date of termination of the quarantine as established by the county governor, but not for more than seven calendar days.
(5) [Repealed – RT I, 30.12.2015, 2 – entry into force 01.01.2016]
(6) [Repealed – RT I, 13.12.2014, 1 – entry into force 01.07.2016 (entry into force amended – RT I, 17.12.2015, 1)]
(7) [Repealed – RT I, 13.12.2014, 1 – entry into force 01.07.2016 (entry into force amended – RT I, 17.12.2015, 1)]
(4) One person adopting a child of under 10 years of age has the right to receive the adoption benefit for 70 calendar days on the basis of a certificate for adoption leave.
(1) An insured person has the right to receive the care benefit on the basis of a certificate for care leave for up to 14 calendar days in the event of nursing a child of under 12 years of age or for up to seven calendar days in the event of nursing another family member at home.
(11) On the basis of a certificate for care leave, an insured person has the right to receive the care benefit for up to 60 calendar days in the event of caring for a child of under 12 years of age if the reason for the illness is a malignant tumour and the treatment of the child commences in a hospital.
[RT I, 11.03.2015, 2 – entry into force 01.07.2015]
(2) On the basis of a certificate for care leave, an insured person has the right to receive the care benefit for up to ten calendar days in the event of caring for a child of under three years of age or for a disabled child of under 16 years of age if the person caring for the child is ill or is receiving obstetrical care.
(3) If a certificate for care leave is issued to several persons caring for one and the same person, the persons will have the right to receive the care benefit for not more than the total number of the calendar days specified in subsections (1) to (2) of this section.
(1) The minister responsible for the field will, by a regulation, establish the terms, rates and procedure of payment of the dental care services benefit payable over one calendar year to a person whom pension for incapacity for work or old-age pension has been granted in accordance with the State Pension Insurance Act or who has been found to have partial work ability or no work ability under the Work Ability Allowance Act and to insured persons of over 63 years of age, pregnant women, mothers of children under one year of age and persons who have an increased need for dental care services as a result of health services provided to them.
(3) The minister responsible for the field will, by a regulation, establish the terms, rates and procedure of payment of the dentures benefit to a person whom pension for incapacity for work or old-age pension has been granted in accordance with the State Pension Insurance Act or who has been found to have partial work ability or no work ability under the Work Ability Allowance Act and to insured persons of over 63 years of age.
(3) A health care provider cannot charge a fee from the insured person for the issue of a document that is necessary for the health insurance fund, a law enforcement authority or another health care provider in connection with the performance of a contract for the provision of health services, assessment of the work ability or determination of the degree of severity of a disability, or in any other events provided by law.
[RT I, 13.12.2014, 1 - entry into force 01.01.2017 (entry into force amended - RT I, 17.12.2015, 1)]
(10) Until the entry into force of clause 54 (1) 1) of this Act on 1 April 2003, the health insurance fund will pay the benefit for temporary incapacity for work to an insured person per calendar day in the amount of 60 per cent of the average income per calendar day in the event of the provision of in-patient health services or caring for a child of under 10 years of age in a hospital.
(17) In the event of medicinal products issued to the insured person before 1 January 2015, the health insurance fund applies the provisions of § 47 of this Act in force until 31 December 2014 upon calculation of the amount of the supplementary benefit for medicinal products.
1Directive 2010/41/EU of the European Parliament and of the Council on the application of the principle of equal treatment between men and women engaged in an activity in a self-employed capacity and repealing Council Directive 86/613/EEC (OJ L 180, 15.07.2010, pp. 1–6); Directive 2011/24/EU of the European Parliament and of the Council on the application of patients’ rights in cross-border healthcare (OJ L 88, 04.04.2011, pp. 45–65). [RT I, 29.11.2013, 1 – entry into force 09.12.2013]
2016 Health Insurance Act
2017 Health Insurance Act
2015 Health Insurance Act
2014 Health Insurance Act