Claims against Employers
The Estonian Health Insurance Fund will recover from the employer reimbursement of health insurance benefits (e.g. benefits for temporary incapacity for work, treatment invoices, reimbursed prescriptions) that the Estonian Health Insurance Fund has paid for or to a person whose insurance cover was not terminated or suspended in a timely manner.
The commencement and period of validity of an employee’s health insurance cover, and consequently the entitlement to health insurance benefits, are directly linked to the entries made in the employment register. Making entries in the employment register entails legal consequences. The maker of the entry is responsible for the correctness of the entry in the employment register.
Examples of situations in which a claim for reimbursement of health insurance benefits is made against the employer
- The employer has made a retroactive entry in the employment register regarding the termination of employment, thereby breaching the obligation to register the termination of employment within the time limit prescribed by law (i.e. within 10 calendar days from the date of termination of employment). If it is established that the person did not have a valid employment relationship for the entire period of the certificate of incapacity for work and therefore was not entitled to the benefit, the Estonian Health Insurance Fund will claim from the employer the temporary incapacity for work benefit paid to the person.
- The employer has annulled the person’s employment entry in the employment register. During the inspection it was established that the person had insurance cover to which they were not entitled and therefore received health insurance benefits without legal basis. The Estonian Health Insurance Fund submits a claim to the employer who failed to correct the incorrect entry in a timely manner and thereby created an erroneous impression that the person had insurance cover.
In addition, the Estonian Health Insurance Fund has the right to recover the unfounded benefit for temporary incapacity for work from the employer of the insured person:
- if unfounded payment of the benefit occurs due to the submission of incorrect information by the employer of the insured person; or
- due to a violation of the prohibition specified in subsection 1 of § 61 of Health Insurance Act, according to which the employer must not allow the insured person to perform work duties during the period covered by a certificate of incapacity for work.