Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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50 Special Solidarity Fund KCE Reports 133 Figure 12: Proportion of completed SSF applications in the SSF sample by year in function of type between 2004 and 2008 (only applications taking longer than 30 days are shown) 5.2.5 Appeal procedure If the patient disagrees with the decisions of the SSF, he can launch an appeal to the labour court (Art. 580, 2° Gerechtelijk Wetboek 17 en art. 167, 1° van de Wet betreffende de verplichte verzekering voor geneeskundige verzorging en uitkeringen, gecoördineerd op 14 juli 1994). 1817 The content of the competence of the labour courts was for a long time under discussion. It was affirmed by jurisprudence and doctrine however that if the College of medical directors judges on the eligibility criteria, this is not a discretionary power. 22 Discretionary power implies freedom of judgement (when a criterion is vague and has to be interpreted) and policy freedom (freedom to decide, even if a situation complies with the criteria). The fact that the College can only strictly apply the legal criteria implies that in case the labour courts have full judicial power (on the reasonability of decision-making and on the content of the decision). With regard to the amount that will be allocated however, the college has discretionary powers. Consequently labour courts solely have the competence to judge the reasonability of decision-making, not the content of the decision (= the amount). This implies that a judge can annul the decision of the College on the allocated amount but not judge on the amount itself. The numbers of registered cases that were introduced to the labour courts varies from 100 in 2004, 74 in 2005, 44 in 2006, 52 in 2007 to 23 in 2008. These numbers reflect the number of cases that were brought to court during those years. They can be related to decisions of the SSF from different years. In the SSF sample, the applications treated by the labour court amount to 144 decisions (1.75% of all applications and 2.56% of all accepted applications). Mostly decisions concerning diseases of the nervous or the circulatory system (see table 8); and implants and drugs are brought before the labour court (see table 9). 17 For an overview of judgments of the labour courts, J. Diependaele, “Het Bijzonder Solidariteitsfonds, blijvende bron van controverses” 19, J. Put, “Het Bijzonder Solidariteitsfonds: interpretatie en beleid”, noot onder Arbeidshof Gent 3 maart 2000 20, W. Bourry, “Het bijzonder solidariteitsfonds: een deur die nooit opengaat”. 21
KCE Reports 133 Special Solidarity Fund 51 Table 8: Applications before labour court in function of ICD-9-CM diagnosis group ICD-9-CM diagnosis group Percentage of all labour court applications Diseases of the Nervous 320-389 System and Sense Organs Diseases of the Circulatory 31,3% 24,8% 390-459 System 16,7% 25,2% 140-239 Neoplasms 13,2% 8,6% 800-999 Injury and Poisoning Diseases of the Genitourinary 6,3% 3,2% 580-629 System Diseases of the Skin and 4,9% 4,9% 680-709 Subcutaneous Tissue Diseases of the Musculoskeletal System and 4,9% 2,4% 710-739 Connective Tissue 4,9% 4,6% 740-759 Congenital Anomalies 4,2% 4,0% 290-319 Mental Disorders Diseases of the Digestive 3,5% 0,9% 520-579 System Diseases of the Respiratory 3,5% 4,7% 460-519 System Endocrine, Nutritional and Metabolic Diseases, and 2,8% 1,5% 240-279 Immunity Disorders Symptoms, Signs and III- 1,4% 10,1% 780-799 defined Conditions Diseases of the Blood and 1,4% 1,8% 280-289 Blood-Forming Organs 0,7% 1,0% Percentage of all applications Table 9: Applications before labour court in function of health care service Health care service Percentage of all labour court applications implants 27,1% 16,9% drugs 25,7% 49,4% instruments, devices, orthosis 16,0% 7,6% innovations 15,3% 13,3% health care abroad 9,0% 3,6% ointments, drugs, bandages skin diseases 2,8% 1,0% fee 2,1% 0,8% special diet 2,1% 2,5% Percentage of all applications
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Optimalisatie van de werkingsprocessen van het Bijzonder ... - KCE

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