Case law
SKGZ
The SKGZ in Zeist is the independent body where insured persons can bring disputes about how their health insurance is administered. That route is anchored in statute: article 114 of the Dutch Health Insurance Act requires health insurers to ensure that their policyholders and insured persons can put disputes to an independent body. The SKGZ offers two routes: the Health Insurance Ombudsman mediates, and the Health Insurance Disputes Committee issues rulings.
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The SKGZ rules on the dispute with the health insurer, not on the care itself or on the conduct of a care provider; other routes exist for that, including professional disciplinary law. The independent body may moreover only take on a dispute once the insured person has asked the insurer to reconsider its decision and the insurer has failed to respond within a reasonable period or has not responded satisfactorily.
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Frequently asked questions
- Is a ruling of the Health Insurance Disputes Committee binding?
- The Disputes Committee rules by way of binding advice, and the public rulings register labels the documents accordingly. That register also contains non-binding advice and interim rulings, so it pays to check which type a ruling is before relying on it.
- What does a procedure before the Disputes Committee cost?
- The applicant pays an entry fee, also called complaint money, of 37 euro. If the request is granted in whole or in part, the committee can order the health insurer to reimburse that amount to the applicant.
- What role does the National Health Care Institute play?
- Article 114(3) of the Health Insurance Act requires the independent body to seek the advice of the National Health Care Institute where the dispute concerns the care or other services referred to in article 11 of that act, or their reimbursement. The institute sends that advice within four weeks of receiving the request. The SKGZ publishes the advice alongside the relevant ruling, so you can see what the committee relied on.
- Does this only concern the statutory basic insurance?
- No. The Disputes Committee also decides disputes about supplementary health insurance, testing those against the policy conditions. The mandatory advice of the National Health Care Institute, by contrast, only covers the care and services referred to in article 11 of the Health Insurance Act, that is the statutory basic package. So a ruling on supplementary cover will not come with institute advice attached.
- What is the difference between the Ombudsman and the Disputes Committee?
- The Health Insurance Ombudsman mediates and looks beyond the letter of the rules, including at whether a measure is being applied fairly; the SKGZ reports that roughly eighty percent of complaints are resolved this way. Where that does not settle matters, the Disputes Committee weighs both positions and issues a ruling.