Source: https://www.riigiteataja.ee/en/eli/ee/525112013009/consolide
Timestamp: 2019-07-16 06:43:28
Document Index: 350196947

Matched Legal Cases: ['§ 6', '§ 7', '§ 6', '§ 6', '§ 7', '§ 57']

§ 6 Duration of insurance cover of officials, active servicemen, members of Riigikogu , President of Republic, members of Government of Republic, judges, Chancellor of Justice, Auditor General, Public Conciliator, members of councils of local authorities, members of city or rural municipality governments, mayors of rural municipality or city districts
§ 7 Duration of insurance cover of persons for whom social tax is paid by state or local authority
5 Benefits in Cash
2 Other Benefits in Cash
(1) For the purposes of this Act, an insured person is a permanent resident of Estonia or a person living in Estonia on the basis of a temporary residence permit or right of residence, 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 terms 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 subsection 22 (1) of this Act.
3) persons for whom the state or a local authority must pay social tax on the basis of § 6 of the Social Tax Act;
5) persons receiving remuneration or service fees on the basis of a contract for services, an authorisation agreement or a contract under the law of obligations for the provision of any other services, which is concluded for a term exceeding three months or for an unspecified term, who are not entered in the commercial register as self-employed persons and for whom the other party to the contract must pay social tax each month on the basis of clause 9 (1) 2) of the Social Tax Act in the amount calculated on the basis of at least the monthly rate established in the state budget for the given budgetary year;
5) students of up to 21 years of age acquiring basic education, students of up to 24 years of age acquiring general secondary education, persons in vocational training without the requirement of basic education, pupils and students acquiring vocational education on the basis of basic education or secondary education in educational institutions of Estonia or equivalent educational institutions of foreign states founded and operating on the basis of legislation, and higher education students who are permanent residents of Estonia.
[RT I 2007, 4, 17 - entry into force 29.01.2007]
§ 6. Duration of insurance cover of officials, active servicemen, members of Riigikogu , President of Republic, members of Government of Republic, judges, Chancellor of Justice, Auditor General, Public Conciliator, members of councils of local authorities, members of city or rural municipality governments, mayors of rural municipality or city districts
(1) The insurance cover of the persons specified in clauses 5 (2) 1) and 2) of this Act will commence upon expiry of a waiting period of fourteen days calculated as of the commencement of employment or taking office if the employer has submitted the documents necessary for an entry on commencement of the insurance cover of the person to be made in the health insurance database to the health insurance fund within seven calendar days as of the date on which the person commences employment or takes office. If the employer submits the necessary documents after expiry of the aforementioned term of seven days, the insurance cover will commence as of the date of making the entry on commencement of the insurance cover in the health insurance database but not earlier than after the retention period of fourteen days calculated from the commencement of work or taking office.
(2) If the documents necessary for an entry on commencement of the insurance cover of a person to be made in the health insurance database are submitted during the period of validity of the insurance cover of the person, the insurance cover will continue on the new basis without interruption.
(3) The insurance cover of the persons specified in clauses 5 (2) 1) and 2) of this Act will terminate two months after termination of the employment relationship or remove from office. The employer must notify the health insurance fund of the termination of an employment or service relationship or removal from office within ten calendar days.
(4) The insurance cover of the persons specified in clauses 5 (1) 1) and 2) of this Act will be suspended after two months have passed from the time when the employer stops paying social tax without terminating the employment relationship with the person or removing the person from office. The employer must inform the health insurance fund about the non-payment of social tax within ten calendar days after stopping the payments.
(5) After recommencing social tax payments following the suspension of the insurance cover, the employer must inform the health insurance fund thereof within ten calendar days as of recommencement of payment of social tax. Upon receipt of the data, the insurance cover will resume without a waiting period.
(6) Subsection (4) of this section will not be applied if the insured person is entitled to the benefit for temporary incapacity for work.
§ 7. Duration of insurance cover of persons for whom social tax is paid by state or local authority
(1) The insurance cover of a person specified in clause 5 (2) 3) of this Act will commence as of the making of an entry on commencement of the insurance cover in the health insurance database. The documents necessary for the person to be entered in the health insurance database must be submitted to the health insurance fund by the agency through which the state or local authority pays social tax for the person.
(2) The insurance cover of a person specified in clause 5 (2) 3) of this Act will terminate one month after the termination of the obligation of the state or local authority to pay social tax for the person. The agency through which the state or the local authority paid social tax for the person must notify the health insurance fund of termination of the obligation to pay social tax within ten calendar days.
(1) The insurance cover of a person specified in clause 5 (2) 4) of this Act will commence upon expiry of a waiting period of three months calculated as of the making of an entry on commencement of the insurance cover in the health insurance database. The documents necessary for the person to be entered in the health insurance database must be submitted to the health insurance fund by the legal person.
(2) If the documents necessary for an entry on commencement of the insurance cover of a person to be made in the health insurance database are submitted to the health insurance fund during the period of validity of the insurance cover of the person, the insurance cover will continue on the new basis without interruption.
(3) The insurance cover of a person specified in clause 5 (2) 4) of this Act will terminate two months after the termination of the person’s authority as a member of the management or controlling body of the legal person. The legal person must submit a notice on termination of the person’s authority as a member of the management or controlling body concurrently with submission of an application to the register registering the members of management or controlling bodies, although the notice must be submitted to the health insurance fund not later than ten calendar days after adoption of the decision on the basis of which the person’s authority as a member of the management or controlling body terminates.
(4) In the event of failure to pay social tax by the due date, the insurance cover of a person specified in clause 5 (2) 4) of this Act will terminate fourteen calendar days after the due date if the obligation to pay social tax has not been performed as required and in full by such time.
(1) The insurance cover of a person specified in clause 5 (2) 5) of this Act will commence upon expiry of a waiting period of three months calculated as of the making of an entry on commencement of the insurance cover in the health insurance database. The documents necessary for the person to be entered in the health insurance database must be submitted to the health insurance fund by the payer of social tax.
(3) The insurance cover of a person specified in clause 5 (2) 5) of this Act terminates two months after termination of the obligation of the person who concluded the contract with them to pay social tax. The payer of social tax must notify the health insurance fund of termination of the obligation to pay social tax within ten calendar days.
(4) In the event of failure to pay social tax by the due date, the insurance cover of a person specified in clause 5 (2) 5) of this Act will terminate fourteen calendar days after the due date if the obligation to pay social tax has not been performed as required and in full by such time.
(6) [Repealed – RT I 2004, 89, 614 – entry into force 01.01.2005]
(1) The insurance cover of a person specified in subsection 5 (4) of this Act will commence as of the making of an entry on commencement of the insurance cover in the health insurance database. The documents necessary for the person to be entered in the health insurance database must be submitted to the health insurance fund by the person themselves or their legal representative or, upon agreement with their employer, by the employer.
(21) If a student of at least 19 years of age acquiring general secondary education as specified in clause 5 (4) 5) of this Act is expelled from the educational institution before graduation within three consecutive academic years after commencement of acquisition of the general secondary education, their insurance cover will terminate one month after the expulsion. If a student of at least 19 years of age acquiring vocational education as specified in clause 5 (4) 5) of this Act fails to graduate from the educational institution within the standard period of study prescribed for completion of the curriculum (except for medical reasons) or is expelled from the educational institution before graduation, their insurance cover will terminate one month thereafter. If a student specified in clause 5 (4) 5) of this Act fails to graduate from the educational institution within one year after the end of the standard period of study prescribed for completion of the curriculum (except for medical reasons) or is expelled from the educational institution before graduation, their insurance cover will terminate one month thereafter.
(1) Information necessary for insurance cover to commence, to be suspended or to terminate must be submitted in unattested written form or in an electronic form that is considered equal thereto.
(3) A person obligated to submit documents or information necessary for insurance cover to commence must perform the obligation within seven calendar days as of the creation of the obligation.
(4) The health insurance fund need not be notified of the termination of insurance cover for a specified term if the insurance cover terminates due to expiry of the term. If a person employed on the basis of a contract for a specified term or employed in the service for a specified period of time continues the employment or public service with the same employer or a state or local authority agency after the expiry of the contract for a specified term or the term of service, the payer of social tax must inform the health insurance fund of the continuance of the employment or service within ten calendar days.
4) information that serves as the basis for payment of health insurance benefits in cash.
(21) The entry on the commencement of the insurance cover of the person specified in clauses 5 (2) 1) and 2) of this Act will be made by the health insurance fund if the Tax and Customs Board has submitted to the health insurance fund the details confirming the payment of social tax by the person. The health insurance fund must inform the insured person and their employer about making the entry within the time limit and in accordance with the procedure prescribed in subsection (3) of this section.
[RT I 2008, 34, 210 - entry into force 01.08.2009]
(1) The following persons are considered equal to insured persons on the basis of a contract:
1) persons who during the two years prior to the month of entry into the contract had been ensured for at least twelve months on the grounds provided for in subsection 5 (2), (3), (31) or clause 5 (4) 5) of this Act, and persons maintained by such persons;
(2) The health insurance fund will conclude a contract specified in subsection (1) of this section with or for the benefit of a person or persons specified in clause (1) 1) or 2) of this section.
(7) A contract will terminate upon commencement of compulsory insurance cover on the basis of this Act.
(1) Health insurance benefit is a high quality and timely health service, necessary medicinal product or medical device which is provided to an insured person under the conditions provided for in this Act by the health insurance fund or a person who has concluded a corresponding contract with the fund (benefit in kind), or a sum of money that the health insurance fund must pay to an insured person under the conditions provided for in this Act for the health care expenses incurred by the person or upon their temporary incapacity for work (benefit in cash).
(4) A health insurance benefit in cash is any of the following that is paid to an insured person by the health insurance fund:
2) adult dental care benefit;
4) the supplementary benefit for medicinal products.
(41) A health insurance benefit in cash will be paid at the expense of the health insurance fund into the bank account of the recipient of the benefit or, on the basis of a written application of the recipient of the benefit into the bank account of a third party in Estonia. A health insurance benefit in cash will be paid into the bank account of the recipient of the benefit in a foreign state at the expense of the recipient of the benefit.
(1) Except in the events provided for in subsection (2) of this section and subsection 36 (3) of this Act, insured persons have the right to receive health insurance benefits in kind only in Estonia.
(2) An insured person may receive health service benefits in a foreign state on the basis of a written contract concluded beforehand between the insured person or their legal representative and the health insurance fund, unless otherwise provided by an international agreement.
(3) Based on an application by an insured person or their lawful representative, the health insurance fund may conclude a contract for the provision of health service benefits to an insured person in a foreign state if:
1) the health service applied for or alternatives to such health service are not provided in Estonia;
2) provision of the health service applied for to the insured person is therapeutically justified;
(31) At least two medical specialists, one of whom must be the medical specialist providing health service to the insured person, must assess the conformity of an insured person to the criteria specified in subsection (3) of this section.
(4) Adult dental care benefit is paid on the conditions provided for in this Act regardless of the place where the expense is incurred.
[RT I 2004, 56, 400 - entry into force 01.08.2004; 1.01.2005]
(3) If there is a waiting list for a health service, the health insurance fund will not assume the obligation to pay for the health service if it is obtained outside the waiting list.
(1) The health insurance fund will assume the obligation of an insured person to pay for a second opinion in accordance with the list of health services of the health insurance fund if the aim of obtaining a second opinion is to ascertain the correctness of a diagnosis, the need and alternatives for or the expected effect of a medicinal product or health service, or the risks relating to the provision of the service.
(2) An insured person also has the right to obtain a second opinion in accordance with the procedure prescribed in subsection 27 (2) of this Act in a foreign state or from a health care provider located in a foreign state.
(3) The conditions and procedure for assumption by the health insurance fund of an obligation of an insured person to pay for a second opinion will be established by a regulation of the Minister of Social Affairs.
(1) The health insurance fund will, to the extent and in accordance with the procedure provided by legislation, assume an obligation to pay for the retail sale of medicinal products and food for particular nutritional uses of medicinal purpose (hereinafter medicinal products), which are necessary for the out-patient treatment of an insured person and are entered in the list of medicinal products of the health insurance fund (hereinafter list of medicinal products).
[RT I, 17.02.2011, 1 - entry into force 27.02.2011]
(1) The interests of insured persons in obtaining necessary medicinal products at a reasonable price, the budgetary funds of the health insurance fund which are prescribed for the assumption of obligations to pay for medicinal products, and the principle provided for in subsection 25 (3) of this Act will be taken into account upon entry into a price agreement.
4) the conditions under which a party has the right to demand that the price agreement be amended;
(51) If no agreement is reached on the conditions for entry into or amendment of a price agreement during a reasonable period of time, the Ministry of Social Affairs may initiate proceedings for the reduction of the reimbursement rate for the medicinal product in accordance with the procedure established in accordance with subsection 43 (3) of this Act.
5) conformity of the medical device with the Medical Devices Act.
(6) The manufacturer of a medical device or an authorised representative of the manufacturer may initiate a proposal for amendment of the list of medical devices by entering into negotiations with the health insurance fund. The State Agency of Medicines or the health insurance fund may initiate a proposal for amendment of the list of medical devices by entering into negotiations with the manufacturer of a medical device or an authorised representative of the manufacturer. The applicant will make public all the circumstances known thereto which are relevant to the negotiations.
Division 5 Benefits in Cash
(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 or city under clauses 6 (1) 1) to 3) and 6) to 13) and subsection (11) of the same section of the Social Tax Act is not taken into account upon calculating the average income per calendar day.
[RT I, 10.06.2011, 7 - entry into force 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.]
Subdivision 2 Other Benefits in Cash
(2) If out-patient specialised medical care is provided without a referral from a person providing general medical care or a person providing specialised medical care, the health insurance fund will not assume the obligation to pay for the health services (additional cost-sharing), except in the events specified in subsection (3) of this section.
(3) If out-patient specialised medical care is provided without a referral from a person providing general medical care or a person providing specialised medical care, the health insurance fund will assume the obligation to pay for the health services if the specialised medical care is provided in connection with a trauma, tuberculosis, eye disease, dermatosis or venereal disease or if gynaecological or psychiatric care is provided or if the provider of specialised medical care leaves the patient under observation or treatment by the provider of specialised medical care due to the state of health of the patient.
(1) A person providing in-patient specialised medical care may charge the in-patient fee from the insured person for the services provided in standard conditions of accommodation. The in-patient fee may be charged for each calendar day that has commenced during the time spent by a person in hospital, but not for more than ten calendar days for one case of illness.
1 Directive 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).