If controversial situations arise - whether specific medical services are covered by the compulsory medical insurance policy, how to deal with a refusal of a quota for surgery and other treatment, how to get free medicine, you need to clearly know what to do if you are denied free medical care to protect your own legal rights.

A consumer rights lawyer in the fight for patient rights will conduct a pre-trial settlement of the dispute and represent your interests in court.

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Refusal of a quota for an operation

Providing a quota for an operation implies treatment of a patient in a clinic at the expense of the state. A similar process is ensured by the corresponding policy - compulsory medical insurance. However, not every disease falls under the quota. In other words, the law defines a list of diseases that can be treated free of charge for a citizen in a public hospital:

• heart diseases
• organ transplantation and prosthetics
• diseases of the nervous system requiring surgical intervention
• medical fertilization for infertility
• diseases caused by hereditary disorders
• high-tech honey help

Since each medical institution is allocated a certain number of patients who can be treated through the compulsory medical insurance policy, for each individual case of quota distribution an independent decision is made indicating the specific hospital for the operation.

To resolve the issue of how to obtain a quota for an operation, at the first stage you need to contact your local doctor, who should initiate the procedure for providing a quota.

Refusal to provide a quota can be at any of the three levels of approval of the procedure - the original doctor, the hospital commission or the regional health department. At the same time, further actions to challenge this refusal do not depend on its level and location.

The reasons for refusal of a quota for an operation can be different - the patient does not have appropriate medical indications for the operation, the citizen does not provide a full package of documents to provide the quota, and so on.

What to do after receiving a refusal of a quota for an operation, where can I complain?

The following options are possible:

1. a complaint addressed to the head of the hospital’s physician, in which, at the initial stage, the doctor of this organization refused to provide a quota;
2. a complaint to the prosecutor's office about illegal denial of medical care;
3. compile (read more at the link);
4. a complaint to the Ministry of Health about a violation of the rules for the provision of medical care.

However, there are cases when there is no time to wait for a hearing on filed complaints and it is necessary to provide treatment at the expense of the citizen himself. In such a situation, it is possible to subsequently go to court with a claim for compensation for losses incurred for treatment (via the link), which was guaranteed to be free. As a result of such proceedings, the court will fully reimburse all expenses for paid medical care from the state treasury.

Denial of subsidized medicine

Providing discounted medications is another state guarantee of free medical care.

At the same time, preferential medications are just one of the ways to implement it. As part of this same process, free sanatoriums and free travel on public transport are possible.

Failure to provide at least one of the three named points is grounds for filing appropriate complaints with government agencies. The question of where to complain about the lack of subsidized drugs is resolved in essence by analogy with the above-mentioned methods of protecting rights - complaints to the prosecutor's office, the Ministry of Health, or possible subsequent judicial reimbursement of expenses incurred for the independent purchase of drugs that should have been free for the citizen.

If a preferential prescription is not issued, the additional addressee of the complaint should be the head. a doctor at a particular hospital who is obliged to conduct an inspection of such a doctor and decide whether to hold this employee accountable.

It is important to note that a citizen has the right, at his own request, to voluntarily refuse to receive the listed guarantees for free medicines. The reasons for this can be completely different - difficulties in obtaining prescriptions, inadequate provision of medications by a medical organization, failure to use public transport, and others.

The first two points can be independent grounds for initiating a solution to the problem of where to complain about the provision of medicines - the lack of necessary medicines is a violation of the law and government agencies must conduct an inspection and establish the reasons for the shortage of medicines.

At the same time, an alternative to this is the right to receive monetary compensation for failure to receive subsidized medications. At the same time, you can refuse all the guarantees at once, or one of the three, leaving, for example, free travel on transport.

As a result of such a voluntary refusal, the citizen receives monthly compensation for non-use of government benefits. To exercise this right, it is necessary to submit an appropriate reasoned application to the pension authorities.

Free medical services

The compulsory medical insurance policy covers the following types of free medical services guaranteed by law:

• - first aid
• - outpatient care
• — inpatient care for acute and chronic diseases
• — assistance during pregnancy, childbirth, abortion
• — sanitary, hygienic disease prevention
• - and so on

Each fact of refusal should be documented, audio-video recordings or the presence of witnesses. It is important to note which specific doctor (full name) or other hospital employee is refusing assistance, as well as the medical institution to which this doctor belongs. In the future, this will help to competently and motivatedly prepare, in law enforcement agencies, to demand compensation for losses incurred and compensation for moral damage.

Payments under the compulsory medical insurance policy

This process is an additional guarantee in the implementation of the rights to free medical care and lies in the fact that a citizen can independently purchase medicines provided to him free of charge, and subsequently demand a refund of the money spent.

Reimbursement for expenses incurred is made by the insurance company from which the compulsory medical insurance policy was obtained. To receive a refund for medicines, you must send a written request to such a company, attaching payment documents about the costs incurred and justifying the need for their purchase, for example, a doctor’s prescription.

It is important to note that actual payment under compulsory medical insurance is possible only if the costs are incurred. No regulatory document provides for separate compensation for unused medical services. Therefore, contacting an insurance organization with reference to non-use of compulsory medical insurance services for several years will obviously not have a positive result and will not constitute a legitimate citizen’s demand.

If you have any questions, call us to protect patient rights: professionally, on favorable terms and on time.

Emergency medical care (EMS) is one of the types of medical care. It is provided to citizens in case of illnesses, accidents, injuries, poisonings and other conditions requiring emergency or emergency medical intervention.

Ambulance, including specialized emergency medical care, is provided to citizens by medical organizations of state and municipal healthcare systems free of charge (clause 3, part 2, article 32, part 1, article 35 of the Law of November 21, 2011 N 323-FZ).

The compulsory health insurance system (CHI) provides all citizens of the Russian Federation with equal rights and opportunities to receive certain types of medical care at the expense of compulsory medical insurance. Evidence that a citizen is a participant in the compulsory medical insurance system is a policy.

Taking into account that EMS can be provided in urgent or emergency forms, as well as outside a medical organization, in outpatient or inpatient settings, various options for actions of EMS employees are possible if a citizen does not have a compulsory medical insurance policy (Part 2 of Article 35 of Law No. 323- Federal Law).

Emergency medical care

Emergency medical care is provided for sudden acute diseases, conditions, exacerbation of chronic diseases that pose a threat to the patient’s life (Clause 1, Part 4, Article 32 of Law No. 323-FZ).

Emergency medical care is provided by a medical organization and medical worker to a citizen immediately and free of charge, and refusal to provide it is not allowed. In this case, the citizen is not required to present a compulsory medical insurance policy (Part 2, Article 11 of Law No. 323-FZ; Clause 1, Part 2, Article 16 of Law dated November 29, 2010 No. 326-FZ).

Emergency medical care

Emergency medical care is provided for sudden acute diseases, conditions, exacerbation of chronic diseases without obvious signs of a threat to the patient’s life (Clause 2, Part 4, Article 32 of Law No. 323-FZ).

In this case, the citizen - the insured person is obliged to present the compulsory medical insurance policy when applying for medical care (clause 1, part 2, article 16 of Law No. 326-FZ).

However, when seeking medical care, a citizen-insured person does not always have the opportunity to present a compulsory medical insurance policy. Below we will consider possible scenarios, provided that:

• the person applying for help has a policy, but is not available at the time of application;
• the person seeking help is insured in the compulsory medical insurance system, but does not have a policy;
• the person seeking help does not participate in the compulsory medical insurance system.

If there is a policy

The patient has a compulsory medical insurance policy, but due to circumstances cannot be presented to the EMS service employee at the time of treatment. For example, the patient became ill on the street, while visiting, on a business trip, at work, at school, in a public institution, etc.

In this case, the EMS doctor (paramedic), based on the results of examining the patient, makes one of the following decisions:

• if the patient’s condition may worsen in the near future and he needs treatment in conditions that provide round-the-clock medical supervision (that is, if it is not excluded that the deterioration of the condition may threaten the patient’s life), then medical care is provided in an emergency manner. In this case, the patient is hospitalized in a hospital;
• If the patient’s condition is stable and the risk of deterioration in health or the development of conditions that threaten the patient’s life is minimal over the next few hours, the patient may not be hospitalized. The doctor transmits information about the accepted call to the clinic at the patient’s place of residence (place of attachment) along with the relevant medical documentation so that the patient can be visited by a local physician (local pediatrician).

In any case, the patient will need to present the doctor with a compulsory medical insurance policy. The local therapist (local pediatrician), when visiting the patient at home, again conducts an examination, assesses the severity of the condition and makes a decision on the type, form and conditions of medical care.

Note. A refusal to hospitalize in the described cases does not constitute a refusal to provide a citizen with medical care. The fact of examining a patient by an EMS employee, assessing the severity of his condition and establishing a preliminary or final diagnosis requires special medical knowledge, qualifications and is a medical service provided.

If there is no policy

The compulsory medical insurance policy is missing, for example lost, stolen, etc., or the degree of wear and tear (damage) is such that it does not allow identification of the insured person.

In addition, a citizen may not have a compulsory medical insurance policy due to refusal to receive it when choosing (replacing) a medical insurance organization. At the same time, despite such a refusal, the insured person retains the right to free medical care in medical organizations participating in the implementation of the territorial compulsory health insurance program throughout the Russian Federation (Letter of the Ministry of Health of Russia dated November 17, 2016 N 17-8/3102029-49381).

In this case, the EMS service employee can act as described above, with the only difference that for persons not identified during the treatment period, the medical organization, including the ambulance service, submits a request to the territorial compulsory medical insurance fund to identify the insured person.

In this case, it is allowed to convey supposed information about the patient from his words if there are no documents proving the patient’s identity.

The Territorial Compulsory Medical Insurance Fund, within five working days from the date of receipt of the application, checks in the unified register of insured persons whether the insured person has a valid policy. The territorial fund submits the results of the inspection to the medical organization within three working days (Rules of compulsory health insurance, approved by order of the Ministry of Health of Russia dated February 28, 2019 N 108n).

Ambulance for uninsured citizens

Ambulance, including specialized emergency medical care, is provided to citizens who are not insured and not identified in the compulsory medical insurance system at the expense of regional budget funds (clause 10 of the Letter of the Ministry of Health of Russia dated December 23, 2016 N 11-7/10/2-8304).

Thus, a citizen who is not insured and not identified in the compulsory medical insurance system has no right to be denied free ambulance, including specialized emergency medical care.

In addition, it is unacceptable to refuse to provide medical care to newborns before issuing a compulsory medical insurance policy, since they are served under the policy of the mother or other legal representative (FFOMS Letter dated May 23, 2016 N 4529/91/i).

The Government of the Russian Federation annually approves the Program of State Guarantees for the provision of free medical care to citizens, which contains information on:

• forms and conditions of medical care,
• diseases and conditions,
• categories of citizens for whom medical care is provided free of charge.

In addition, it contains information on average standards for the volume of medical care, average standards for financial costs per unit of volume of medical care, average per capita financing standards, as well as the procedure and structure for setting tariffs for medical care and methods of payment.

It is important that the state guarantee program contains a basic compulsory medical insurance program, as well as requirements for territorial compulsory medical insurance programs of constituent entities of the Russian Federation, where the programs may differ from the basic one due to the specifics of the region.

To receive the free medical care mentioned in the program, a citizen of the Russian Federation must obtain a compulsory medical insurance policy. The entire procedure for dealing with a compulsory health insurance policy is very clearly regulated at the legislative level. And every person should know their rights and responsibilities when using such a document.

What services are provided free of charge?

According to their compulsory medical insurance policy, each person can use ambulance services free of charge, receive outpatient care, including at home, and also visit a day hospital. In addition, the policy guarantees free planned hospitalization.

The compulsory health insurance program pays special attention to pregnant women, so such complex medical procedures as childbirth are also paid for through compulsory medical insurance.

Compulsory medical insurance does not include: treatment of sexually transmitted diseases, tuberculosis, HIV infection and acquired immunodeficiency syndrome, mental disorders and behavioral disorders. However, treatment of these diseases is also free for citizens of the Russian Federation, since they are paid from the budget of the constituent entities of the Russian Federation.

Treat, you can’t refuse

There is also a nuance: if suddenly a person gets into trouble - he lost consciousness, suffered a fracture, felt pain in his heart, was injured, etc., he can call an ambulance or go to the emergency room, and they are required to admit him there even without presenting an insurance policy. Compulsory medical insurance. Emergency medical care is provided immediately and without bureaucratic delays. The policy may be asked to present later, when the person’s life and health are not in danger.

Since 2011, a uniform compulsory medical insurance policy has been in force in Russia - this means that its effect extends throughout the country, and a person who finds himself in another region can receive the necessary medical care upon presentation of the compulsory medical insurance policy.

Issue and change

All Russian citizens can apply for a policy at compulsory medical insurance policy issuance points, which are located in any city. Just to begin with, you need to choose a medical insurance company that will accompany the insured. You can change your insurance policy once a year, so you need to approach your choice responsibly.

To obtain a policy, you will need a number of documents. For adult citizens and children over 14 years of age, this is a Russian passport and SNILS; for children, this is a birth certificate, documents of their legal representative and SNILS. Everyone also needs to write an application for the issuance of a policy.

The insured is obliged

There are only 4 responsibilities of the insured that should be known and observed. This:

• present a compulsory medical insurance policy when seeking medical care, with the exception of cases of emergency medical care;
• submit to the medical insurance organization personally or through your representative an application for choosing a medical insurance organization in accordance with the rules of compulsory health insurance;
• notify the medical insurance organization of changes in last name, first name, patronymic, place of residence within one month from the day these changes occurred. In cases of change of surname, name, patronymic, the policy is reissued;
• select a medical insurance organization at a new place of residence within one month in the event of a change of residence and the absence of a medical insurance organization in which the citizen was previously insured.

On the territory of the Russian Federation, Federal Law dated November 29, 2010 N 326-FZ (as amended on December 1, 2014) “On compulsory health insurance in the Russian Federation”

I consider the doctor’s refusal to be unlawful and must first be appealed by filing an application addressed to the chief physician of the medical institution, then to the court.
The reasons are as follows:
This Federal Law regulates relations arising in connection with the implementation of compulsory health insurance, including determining the legal status of subjects of compulsory health insurance and participants of compulsory health insurance, the grounds for the emergence of their rights and obligations, guarantees for their implementation, relations and responsibilities associated with the payment of insurance contributions for compulsory health insurance of the non-working population.

In this regard, you are guaranteed the following:
Chapter 4. RIGHTS AND OBLIGATIONS OF INSURED PERSONS, POLICIES, INSURANCE MEDICAL ORGANIZATIONS AND MEDICAL ORGANIZATIONS
Article 16. Rights and obligations of insured persons
1. Insured persons have the right to: 1) free medical care provided by medical organizations upon the occurrence of an insured event: a) throughout the Russian Federation in the amount established by the basic compulsory medical insurance program;

According to the adopted legislation, almost every person registered and living on the territory of the Russian Federation has the right assigned to him to apply to any medical institution to receive appropriate treatment if such a need arises. However, there is one important nuance - services of this kind, as well as the right to receive medications free of charge, that is, free of charge, are provided only if the citizen has a document such as a compulsory health insurance policy.

Who can receive free medical services?

Any citizen who owns the following has the right to use the services of medical institutions:

• Employed citizens. That is, the category of persons who regularly pay taxes to the state budget. That is, in essence, he pays for his treatment in advance.
• Unemployed citizens. In this case, payment of funds for the treatment of these persons also occurs at the expense of the federal budget.
• Children, teenagers, and who have not reached the age of eighteen and are not taxpayers.

If a person is officially employed, he has the right to register, as well as . If he is not employed, works unofficially, or has not reached the age of majority, you can apply for the specified document to any company that provides insurance services.

In the event that a citizen needs to see a specialist who is receiving treatment outside the locality where the specified individual lives, a referral from the attending physician is also required.

There is a certain list of medical services, the provision of which is free of charge. These include the following:

1. Emergency assistance, that is, the departure of an ambulance when a patient is called. This service is provided free of charge not only to persons who have, but also to those who do not have this document. In the recent past, there were unreliable rumors that if a person does not have a compulsory health insurance policy, he will have to pay about one and a half to two thousand rubles to call an emergency room. This is wrong. This service is provided absolutely free of charge in any case.
2. Ambulatory treatment in a medical institution that is part of the insurance system and includes a number of different manipulations: examination and diagnosis of the patient’s disease, performing the necessary procedures and prescribing adequate treatment. However, when a patient is under so-called outpatient, daytime or home treatment, all necessary medications must be purchased by him at his own expense, since there are no benefits in this case.
3. Working with the public to raise awareness of sanitary and hygienic issues. That is, holding various lectures, seminars and so on.
4. Diagnosis and treatment of the population using expensive innovative drugs and methods. For example, in some regions of the Russian Federation, in vitro fertilization is carried out free of charge.
5. Diagnosis of the disease followed by hospitalization.
6. in dental clinics and offices that have state status.

Free services under compulsory medical insurance policy

For example, while undergoing treatment in a state hospital, a citizen has the right to receive free services for the treatment of diseases of the following kind: support of pregnancy during its complicated course, as well as in the presence of pathologies of any kind, medical abortion, the presence of chronic diseases, or in case of exacerbation of the disease, poisoning , causing bodily harm and so on. In this case, the provision of medications necessary for adequate treatment is provided free of charge.

The diseases that, according to the list, are treated free of charge include the following:

1. Diseases of an infectious nature, with the exception of those categories classified as sexually transmitted infections.
2. Various diseases of the blood, vascular system, heart.
3. Diseases of the stomach, as well as the gastrointestinal tract in general.
4. Any disease caused by a nervous disorder.
5. Diseases of joints, bones, muscles and so on.
6. All kinds of defects in vision, hearing, speech.
7. Tumors of both benign and malignant nature.
8. Diseases of tissues and skin.
9. Diseases of the genitourinary area.
10. Diseases of the respiratory system.

What to do if treatment is denied if you have a policy?

Currently, not every citizen is fully aware of the rights that are granted to him in accordance with this, which is often taken advantage of by unscrupulous workers in this field of activity, demanding a certain payment for the provision of the necessary assistance.

What to do if your rights are violated

Every citizen of the Russian Federation who has insurance has the right to seek help from any medical institution located on the territory of the state. The specified institution is obliged to admit him and carry out appropriate diagnosis, treatment, as well as other manipulations that are necessary.

However, it often happens that doctors, as well as hospital staff, refuse to admit the patient in such cases. This is not legal and violates human rights. It is important to produce.

To restore the violated right, a person who has been denied medical services must file a complaint with the medical service, whose employees will take appropriate measures. If such a case is detected, administrative penalties may be applied to medical service workers.

What can you expect with a compulsory medical insurance policy?

In order to know which services the compulsory health insurance policy gives you, you need to carefully read the list of services provided to the population free of charge. It should be remembered that, in essence, these services are not at all free due to the fact that a certain amount intended specifically for this purpose is deducted from the salary of each employed citizen every month. Consequently, in this way, each individual pays in advance for his treatment in a state-type institution. .