The Ombudsman once again draws attention to the delay of the ZZZS in making a decision in the case of an appeal against the decision of the appointed doctor

28. 2. 2024 | Social security

Summary

The Ombudsman was contacted by a complainant, who criticised the Health Insurance Institute of Slovenia for the length of the procedure in connection with a complaint against the decision of an appointed doctor. The Ombudsman found that the Health Insurance Institute of Slovenia, by failing to issue a decision within the statutory deadline, violated the complainant's right to social security from Article 50 of the Constitution of the Republic of Slovenia and the principle of good governance from Article 3 of the Ombudsman Act.

Details

The Ombudsman once again draws attention to the delay of the ZZZS in making a decision in the case of an appeal against the decision of the appointed doctor

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The Ombudsman of the Republic of Slovenia (Ombudsman) received an complaint alleging that the Health Insurance Institute of Slovenia (ZZZS) did not decide on an appeal against the decision of the appointed doctor in accordance with Article 82 of the Health Care and Health Insurance Actabout:blank#_ftn2 (ZZVZZ), which stipulates that the commission must issue a decision on its decision no later than eight days after receiving the appeal. At the same time, the ZZZS explained that, given the workload of the health commission, it unfortunately cannot guarantee a shorter deadline in cases of requested personal treatment.

The Ombudsman assessed the complaint as well-founded. Pursuant to Article 82 of the ZZVZZabout:blank#_ftn3 the insured person or the employer may appeal the decision on the appointment of a doctor within five working days of service of the decision. The appeal is considered by the medical commission, which is appointed by the management board of the institution and consists of two doctors and one university graduate in law. The commission issues a decision on its decision no later than eight days after receiving the appeal.

The Ombudsman can understand the reasons for delays in the issuing of decisions by the ZZZS, but in the opinion of the Ombudsman, it is unacceptable that because the ZZZS is unable to ensure a decision within the statutory time limits, the burden of delays is transferred to insured persons, who are consequently not informed in time whether they were successful with their appeal or not. In the Annual Report for 2022, the Ombudsman once again warned that the ZZZS often issues decisions on the extension of sick leave retrospectively and after the deadline has passed, and that the ZZZS has repeatedly pointed out this practice in direct contact, as in the opinion of the Ombudsman, the ZZZS thereby violates the right to social security and the principle of good governance. Therefore, the Ombudsman in recommendation no. 30 (2022) recommended to the Ministry of Health and ZZZS that they take the necessary measures to ensure an adequate number of appointed doctors at the ZZZS. It is an unfulfilled recommendation that the Ombudsman repeats. The same applies for recommendation no. 38 (2022), in which the Ombudsman recommended that the ZZZS take appropriate measures regarding the decision-making on appeals against decisions on temporary incapacity for work in such a way that unnecessary delays no longer occur. 9.3-11/2023

about:blank#_ftnref1 Recommendation no. 30 (2022).