Source: https://www.enerkemi.fi/englishinfo/10606
Timestamp: 2019-12-09 17:48:43
Document Index: 119854533

Matched Legal Cases: ['§96', '§97', '§100', '§27', '§11', '§2']

English info | Vakuutuskassa Enerkemi
THE ENERKEMI INSURANCE FUND
The purpose of the Fund is to grant both benefits in accordance with the Sickness Insurance Act and certain additional benefits according to the rules of the Fund. The Fund operates as a employees´sick fund. All employees whose main income come from the employers mentioned in the rules are members, but the membership is voluntary. However, persons who are temporarily or short-term employed do not belong to the Fund.
Persons employed by the companies mentioned in the rules are entitled to join the Insurance Fund. Application for a membership shall be submitted within 4 months from the start of one´s employment. If a member transfers directly to employment with another participating company, his/her membership in the Fund is maintained. Membership is voluntary.
The Board of the Insurance Fund shall approve of a membership. The membership will begin from the beginning of the calendar month succeeding the Board´s approval.
The membership in the Insurance Fund will be terminated from the beginning of the calendar month after termination of the employment.
The membership fee of the Fund is 0.31 % of the member´s taxable salary received from an employer. However, the minimum fee is 8,86 € and the maximum 17,76€ per month. The minimum and maximum fees are bound to wage factor according to the Employees´ Pensions Act , §96, §97 and §100, so that the amounts mentioned correspond to index figure 1,363..
The Employer’s contribution is 218 % of the total amount of its members´ fees.
Benefits according to the sickness insurance Act in accordance with the Sickness Insurance Act, a member is entitled to have:
1) a refund of costs of necessary medical treatment caused by an illness
2) Daily allowance for disability due to illness
3) A refund of costs due to pregnancy or confinement
4) Maternity, paternity and parenthood allowance as well as special maternity allowance
5) Special care allowance
6) Daily allowance and refund for loss of earnings mentioned in §27 of the Act of Infectious Disease, and
7) Daily allowance according to §11 of the Act concerning detachment of human organs and tissues for medical purposes.
The member is entitled to a refund of costs caused by necessary treatment, when the member due to illness, pregnancy or confinement has to seek medical assistance. Costs will be refunded only for the part they exceed the corresponding benefits granted on the basis of the Sickness Insurance Act.
The Fund refunds 75 % of the following costs:
a) medical fees, in case of necessary examination or treatment to cure any other illness than dental diseases
b) medical fees of non-institutional care in a health centre, in an A-clinic or in an occupational health station, excluding charges for dental care and polyclinic fees in a general hospital
c)office expenses for an examination or treatment institution up to a maximum amount of 8,00 € per refund.
Daily fee for treatment in a general hospital, a private hospital or a health centre, however, the compensation being calculated according to the lowest fee category of a central hospital and paid for one illness for a period of 100 days at the most.
a) prescribed medicine, vitamins, trace elements, clinical nutritive preparation and products similar to these and basic ointments in case they are reimbursable also according to the Sickness Insurance Act.
b) prescribed medicine not reimbursed according to the Sickness Insurance Act, to a maximum of 670,00 € / member per one calendar year.
a) prescribed laboratory and X-ray examinations provided that they are also reimbursable according to the Sickness Insurance Act,
b) prescribed physical treatment provided that it is reimbursable also according to the Sickness Insurance Act,
c)prescribed cytostatic treatment and hemodialysis as well as phototherapy provided that the costs are reimbursable according to the Sickness Insurance Act;
d) prescribed chiropractic, naprapathy and osteopathy treatment, however, so that the maximum refund is 250,00 € / member during a calendar year.
The nurse shall be a professional duly registered in the Health Care Centre of Legal Protection (see a list on Intranet)
e) prescribed uric treatment of nails.
a) necessary travel costs connected to health care (for example, travel costs to a doctor´s reception) and to buying or maintaining appliances prescribed by a doctor provided that costs are reimbursable also according to the Sickness Insurance Act. Travel costs will be refunded based on the cheapest way of travel, unless the nature of illness or traffic conditions absolutely require other means of transportation.
b) travel costs caused by a doctor or another professionally qualified person to see the patient, provided that the costs are reimbursable also according to the Sickness Insurance Act.
a) spectacles prescribed by a doctor or an optician, however, so that the maximum amount of the refund is 200,00 € for mono-effective lenses, 400,00 € for multi-effective lenses, 130,00 € for contact lenses and 130,00 € for frames per refund. Spectacle frames will be refunded every second year at the earliest. The refund is paid either for spectacles or contact lenses once per calendar year. Those entitled to these benefits must have been members in the Fund for at least one year without a break.
b) fees for sight test and fitting of contact lenses charged by an optician.
Those who have been members for at least one year without a break are refunded costs of dental care by any other treatment than mentioned in point 1, so that the maximum amount of benefit is 1000,00 € /member per calendar year. All dental care operations performed by a dentist, a dental technician and a dental assistant and the pertaining costs will be refunded.
The fee for a maximum of one treatment per calendar year in an intoxicantabuser institution or detoxification center. The refund is calculated according to the lowest fee level of a central hospital.
Prescribed surgical stockings, back braces, orthopedic supports,appliances, hearing aids and prostheses for a maximum of 200,00 € /member per calendar year, if it is not possible to have them free of charge either permanently or temporarily. The Fund´s responsibility for a refund is limited to the maximum amount that benefits received elsewhere have been taken into account.
Exceptions to the above mentioned refundable costs:
When a treatment falls into the special fee category in a private health care institution, the maximum additional refund for surgeries or treatments comparable to surgery and performed in a general hospital is 1500,00 €/ member per calendar year, excluding the benefit paid according to paragraph 2b.
The examination or treatment should be done by a person with an appropriate professional qualification, or the treatment/examination has to be done in an institution referred to in §2 (1) section of the Sickness Insurance Act.
Treatment given abroad will be refunded at the maximum by the amount that the treatment would have cost if done in Finland. Travel costs abroad will not be refunded.
The Insurance Funds liability begins at the beginning of the membership and expires at the termination of the membership. The Insurance Funds liability is determined by the timing of the insurance event.
Costs of such insurance incidents, which take place during unpaid vacation or any other unpaid period of time when the person is not working, and those working as an expatriate (during the validity of the expatriate contract), will not be refunded. An interruption in salary payment due to illness/accident or due to maternity, paternity or parenthood leave does not have an effect on the payment of additional benefits as long as the membership in the Fund continues.
The additional benefits in accordance with these rules have to be claimed literally. Necessary documents and clarifications have to be enclosed to the application. Refunds have to be claimed within six months from the payment of the costs.
Note! This is an abridged summary of benefits offered by the Insurance Fund.
For more information or precise rules, please contact us by e-mail enerkemi@fortum.com