Background of the Case
The Supreme Court of Cassation, Second Commercial Department, Fourth Chamber ruled with Decision No. 1 dated 08.01.2025, under cassation commercial case No. 1522 from 2023 on a question regarding the starting moment from which the National Health Insurance Fund (“NHIF”) falls into delay of payment of rendered medical care
Key Legal Question
What is the starting point from which the NHIF falls into delay for payment of remuneration for the performed and reported by the contractor medical aid – above the limits set by the contract?
Invalidated Provision of the Health Insurance Act
The Constitutional Court of the Republic of Bulgaria invalidated as unconstitutional the provision of Art. 55a, para. 2 of the Health Insurance Act, which stated that the NHIF does not pay for medical and dental care provided by medical facilities in violation of the agreements specified in their contracts volumes and values under Art. 59, para. 1.
However, this normative rule limits the right to health insurance under the Constitution of the Republic of Bulgaria, because its application does not contribute to the accessibility of medical or dental care, on the contrary, it makes it more difficult to access.
The Court’s Interpretation
The judicial panel accepts that the NHIF is obliged to pay for any duly rendered, reported and accepted medical assistance, included on the basis of Art. 45, para. 2 Health Insurance Act, in connection with Art. 45, para. 1 of the same act, in the basic package of health activities, which should be guaranteed by the budget of the NHIF, thus ensuring the possibility of affordable medical assistance for every citizen with health insurance, which is one of the normative goals.
Accessibility to Medical Care
Mandatory health insurance guarantees free access of insured persons to medical assistance through a package of health activities determined by type, scope and volume, as well as free choice of a contractor who has entered into a contract with a Regional Health Insurance Fund. In this sense, it is inadmissible to establish specific limits (volumes) of medical activities for specific providers of medical care, such as the agreed upon in the individual contracts concluded with the NHIF. Therefore, the medical care provider cannot refuse to provide medical services to a health insured patient.
Payment Obligations of the NHIF
Considering the above, upon exact (in terms of quality and time) fulfilment of their legal obligations, arising from the individual contract concluded with the NHIF in accordance with Art. 59, para. 1 of the Health Insurance Act, in connection with Art. 20, para. 1, item 4 of the Health Insurance Act, a payment obligation arises – the obligation to pay the value for the hospital care provided during the relevant reporting period on clinical paths, regardless of whether it is above the limits set by the individual contract.
Compensation for Delayed Payments
When the individual contract stipulates a term for the fulfilment of the payment obligation, when this term expires, not only does it become due, but the debtor also falls into default. From that moment, an obligation to pay compensation for the property damage caused to the contractor arises due to inaccurate fulfilment in terms of time of the legal obligation to pay the agreed monetary remuneration by the NHIF, including when the monetary remuneration is above the specified limits.
