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Dôvody pre odmietnutie súhlasu s liečbou v zahraničí


 | 10.9.2013 | komentárov: 287

V sekcii judikatúra sme zaradili rozhodnutie Súdneho dvora EÚ týkajúce sa dôvodov, pre ktoré možno neudeliť súhlas s liečbou v zahraničí (C 372/04)

Yvonne Watts je britskou občiankou, ktorá trpela artritídou bedrových kĺbov.  V záujme liečenia svojej choroby chcela podstúpiť operáciu mimo územia Veľkej Británie. Keďže pohyblivosť pani Watts bola značne obmedzená, britský odborný lekár odporučil zaradiť jej prípad medzi ostatné prípady pacientov s akútnou artritídou. Bedforf PCT sa však podľa tohto odporúčania neriadil a prípad pani Watts zaradil k rutinným prípadom, pre ktoré je príznačná jednoročná čakacia doba pred podstúpením zákroku v miestnej nemocnici a zároveň zamietol jej žiadosť o vydanie formulára E – 112 umožňujúceho podstúpenie liečby v zahraničí, keďže usúdil, že pacientka môže podstúpiť liečbu svojej choroby aj v miestnom zdravotníckom zariadení. V tejto situácii podala pani Watts návrh na zaťatie konania, ktorého účelom by bolo preskúmanie rozhodnutia o zamietnutí jej žiadosti. V marci 2003 podstúpila pani Watts operáciu vo Francúzsku s cieľom voperovať protézu bedrového kĺbu. Náhrada nákladov vynaložených v súvislosti s lekárskym zákrokom bola následne uplatnená u Bedford PCT, ktorý ich uhradiť odmiertol. High Court of Justice (England & Wales) Queen’s Bench Division (Administrative Court), na ktorý sa pani Watts obrátila za účelom preskúmania rozhodnutia Bedford PCT, zamietol jej návrh. Proti tomuto rozhodnutiu pani Watts spolu s Secretary of State for Health podali odvolanie na Court of Appeal, Civil Division, ktorý sa rozhodol preušiť konanie pre ním a položiť Súdnemu dvoru EÚ sedem prejudiciálnych otázok:
„1.      Má sa článok 49 ES so zreteľom na charakter NHS a jeho postavenie vo vnútroštátnom práve vykladať vo svetle rozsudkov Smits [a Peerbooms], Müller-Fauré [a van Riet], ako aj Inizan tak, že v zásade sa osoby, ktoré majú zvyčajné bydlisko na území Spojeného kráľovstva, môžu podľa práva Spoločenstva domáhať poskytnutia nemocničnej starostlivosti v iných členských štátoch na náklady NHS?
Najmä pokiaľ ide o výklad článku 49 ES:
a)      Existuje rozdiel medzi vnútroštátnym zdravotníckym systémom financovaným štátom, akým je napríklad NHS, na jednej strane, a poisťovňami, ako je napríklad holandský systém ZFW, na druhej strane, najmä so zreteľom na skutočnosť, že NHS nemá vyčlenený žiadny fond, z ktorého by sa vykonávali platby?
b)      Je NHS povinný povoliť a uhradiť túto starostlivosť poskytnutú v inom členskom štáte, hoci nie je povinný povoliť a uhradiť túto starostlivosť, pokiaľ je poskytnutá súkromným poskytovateľom v Spojenom kráľovstve?
c)      Je relevantnou skutočnosť, že si pacient zabezpečí ošetrenie nezávisle od príslušnej inštitúcie NHS a bez predchádzajúceho povolenia alebo oznámenia?
2.      Je na zodpovedanie prvej otázky podstatné, či nemocničná starostlivosť poskytovaná NHS je sama osebe poskytovaním služieb v zmysle článku 49 ES?
V prípade kladnej odpovede a za okolností uvedených vyššie v opise skutkového stavu, majú sa články 48 [ES], 49 [ES] a 50 ES vykladať tak, že v zásade:
a)      nemocničná starostlivosť poskytnutá príslušnými inštitúciami NHS predstavuje poskytnutie služieb v zmysle článku 49 ES;
b)      pacient, ktorý využíva nemocničnú starostlivosť na základe NHS, ako taký vykonáva svoje právo prijímať služby v zmysle článku 49 ES a
c)      inštitúcie NHS poskytujúce nemocničnú starostlivosť sú poskytovateľmi služieb v zmysle článkov 48 [ES] a 50 ES?
3.      Ak sa článok 49 ES vzťahuje na NHS, môže NHS alebo minister objektívne odôvodniť svoje odmietnutie poskytnúť predchádzajúce povolenie poskytnúť nemocničnú starostlivosť v inom členskom štáte tým, že:
a)      toto povolenie by vážnym spôsobom narušilo systém NHS spočívajúci v spravovaní liečebných priorít prostredníctvom poradovníkov;
b)      toto povolenie by umožnilo pacientom, ktorí potrebujú menej naliehavý lekársky zákrok, získať prednosť pred pacientmi, ktorí potrebujú naliehavejší lekársky zákrok;
c)      toto povolenie by malo za následok presmerovanie zdrojov na úhradu za menej naliehavé ošetrenie pre pacientov, ktorí sú ochotní cestovať do zahraničia, na úkor tých, ktorí nie sú ochotní alebo nie sú schopní cestovať do zahraničia, alebo by sa zvýšili náklady inštitúcií NHS;
d)      toto povolenie môže zaväzovať Spojené kráľovstvo, aby poskytlo dodatočné financie do rozpočtu NHS alebo obmedzilo rozsah ošetrenia dostupného v rámci NHS;
e)      porovná náklady na ošetrenie a vedľajšie náklady z neho plynúce v inom členskom štáte?
4.      Do akej miery je pri posudzovaní toho, či je ošetrenie dostupné ‚bez zbytočného odkladu‘ na účely článku 49 ES, potrebné alebo prípustné zohľadniť najmä tieto kritériá:
a)      čakacie doby;
b)      klinickú prioritu starostlivosti určenú príslušnou inštitúciou NHS;
c)      organizáciu poskytovania nemocničnej starostlivosti v súlade s prioritami zameranými na dosiahnutie čo najlepšieho výsledku pri obmedzených zdrojoch;
d)      skutočnosť, že ošetrenie poskytované v rámci NHS je bezplatné v mieste, kde je pacient ošetrený;
e)      konkrétny zdravotný stav pacienta, ako aj jeho zdravotné záznamy a pravdepodobný ďalší priebeh ochorenia, o ktorého ošetrenie pacient žiada?
5.      Pokiaľ ide o správny výklad článku 22 ods. 1 písm. c) nariadenia [č.] 1408/71 a predovšetkým výrazu ‚v čase zvyčajne potrebnom pre obdržanie tejto starostlivosti‘:
a)      sú uplatniteľné kritériá totožné s kritériami, ktoré sa uplatnia pri otázke ‚zbytočného odkladu‘ na účely článku 49 ES?
b)      ak nie, v akom rozsahu je potrebné alebo prípustné zohľadniť faktory vymenované v štvrtej otázke?
6.      V prípade, keď členský štát je podľa práva Spoločenstva povinný financovať nemocničnú starostlivosť poskytnutú v iných členských štátoch osobám, ktoré majú zvyčajné bydlisko v skôr uvedenom členskom štáte, majú byť náklady tejto starostlivosti vypočítané na základe článku 22 nariadenia [č.] 1408/71 podľa právneho poriadku členského štátu, v ktorom sa starostlivosť poskytuje, alebo na základe článku 49 ES podľa právnej úpravy členského štátu bydliska?
V každom prípade:
a)      Aký je presný rozsah povinnosti uhradiť alebo nahradiť náklady na nemocničnú starostlivosť, najmä pokiaľ je táto starostlivosť, ako je to v prípade Spojeného kráľovstva, poskytovaná pacientom bezplatne v mieste, kde sú ošetrení, a neexistuje žiadny vnútroštátny sadzobník náhrad nákladov za ošetrenie pacientov?
b)      Obmedzuje sa táto povinnosť na skutočné náklady na poskytnutie rovnakého alebo rovnocenného ošetrenia v prvom členskom štáte?
c)      Zahŕňa táto povinnosť aj povinnosť nahradiť cestovné a ubytovacie náklady?
7.      Má sa článok 49 ES a článok 22 nariadenia č. 1408/71 vykladať tak, že tieto články ukladajú členským štátom povinnosť financovať nemocničnú starostlivosť poskytnutú v iných členských štátoch bez ohľadu na obmedzenia rozpočtovej povahy, a ak áno, sú tieto požiadavky zlučiteľné so zodpovednosťou členských štátov za organizáciu a poskytovanie zdravotníckych služieb a zdravotnej starostlivosti, ktorá je zakotvená v článku 152 ods. 5 ES?“

Súdny dvor vo výroku svojho rozhodnutia uviedol, že odmietnutie udelenia súhlasu s liečbou na území iného členského štátu „z dôvodu založeného na existencii čakacej doby na nemocničnú liečbu, musí dokázať, že táto doba neprekračuje prijateľnú dobu vyplývajúcu z objektívneho medicínskeho posúdenia klinických potrieb dotknutej osoby s prihliadnutím na všetky parametre, ktorými sa vyznačuje stav jej choroby v čase podania, prípadne opätovného podania, žiadosti o súhlas.” V prípade ak osoba podstúpi liečbu na území iného členského štátu za odplatu, nie „je potrebné skúmať, či je nemocničná starostlivosť poskytovaná v rámci vnútroštátneho systému, do ktorého patrí táto osoba, sama osebe službou v zmysle ustanovení o slobodnom poskytovaní služieb.”  Odmietnutie udelenia súhlasu s liečbou v zahraničí možno len po predchádzajúcom posúdení zdravotného stavu osoby, jej zdravotných záznamov, vývoja choroby, stupňa bolesti pri podávaní žiadosti o súhlas „za predpokladu, že právna úprava príslušného členského štátu stanovuje bezplatnosť nemocničnej starostlivosti poskytovanej vo vnútroštátnom zdravotníckom systéme, a v prípade, že právna úprava členského štátu, v ktorom bol alebo mal byť pacientovi patriacemu do tohto systému poskytnutý súhlas s tým, aby mu bola poskytnutá nemocničná liečba na náklady tohto systému, nestanovuje úplné prevzatie nákladov na túto liečbu, musí príslušná inštitúcia poskytnúť tomuto pacientovi náhradu zodpovedajúcu prípadnému rozdielu medzi objektívne vyčíslenou sumou nákladov na porovnateľnú liečbu v zariadení patriacom do tohto systému, obmedzenou v prípade potreby výškou celkovej sumy vyúčtovanej za liečbu poskytnutú v členskom štáte pobytu, a sumou, ktorú je povinná nahradiť inštitúcia tohto členského štátu”. Súdny dvor taktiež uviedol, že ak bol pacientovi poskytnutý súhlas s vycestovaním za účelom liečby v zahraničí, alebo bol tento súhlas nedôvodnene zamietnutý, má právo „požadovať od príslušnej inštitúcie prevzatie vedľajších nákladov súvisiacich s týmto cezhraničným presunom na medicínske účely, pokiaľ právna úprava príslušného členského štátu ukladá vnútroštátnemu systému zodpovedajúcu povinnosť prevziať náklady v rámci liečby poskytovanej v miestnom zariadení patriacom do tohto systému.”



Spracovala: Ľudmila Moľová
Zdroj: http://curia.europa.eu/juris/document/document.jsf?docid=56965&mode=req&pageIndex=7&dir=&occ=first&part=1&text=povinnost%2Blekara&doclang=SK&cid=4237085#ctx1




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