Voluntary health insurance: what it covers and how to use it in Niš

Compulsory health insurance is administered by Serbia's Republic Health Insurance Fund (RFZO). It entitles you to treatment at health centres, hospitals and other facilities that have a contract with RFZO, usually with a referral from your registered GP.

Voluntary health insurance is a separate policy that you take out yourself or through your employer, usually with an insurance company. By law, RFZO can also offer voluntary insurance. For people who have compulsory insurance, voluntary insurance does not replace it but adds to it. The contract usually runs for one year. The policy sets out exactly what is covered, up to what amount and at which facilities.

Serbia's Health Insurance Act distinguishes three types of voluntary insurance:

• Complementary (dopunsko): adds to the rights under compulsory insurance in terms of content, scope and standard.
• Supplementary (dodatno): covers co-payments, as well as services, medicines and medical devices that compulsory insurance does not cover.
• Private (privatno): intended for people who are not covered by compulsory insurance.

In practice, policies often combine these types. In everyday speech, and even on insurers' websites, any such policy is often called private health insurance, although the law uses that name only for the insurance of people without compulsory insurance. That is why what your policy says matters more than what the package is called.

Cover depends on the package you have taken out. Packages are usually divided into outpatient and hospital treatment, each with its own limit. The limit is the amount up to which the insurer pays costs while the policy is in force. For certain services, for example operations or scans, the policy may also have a separate, lower limit.

• Outpatient treatment: consultations with GPs and specialists, laboratory tests and diagnostics, for example ultrasound and X-ray. Some packages also cover minor outpatient procedures up to a certain amount.
• Hospital treatment: operations, anaesthesia, the hospital stay and meals, and medicines and medical supplies during treatment, up to the agreed limit. Some packages also include outpatient treatment, and some cover hospital treatment only.
• Insurance for surgical procedures: some companies also offer a policy that pays you an agreed sum of money after an operation, according to the table of procedures in the policy terms. This type of policy does not pay the hospital bill, so you usually pay for the operation yourself and receive the benefit from the insurer afterwards.

Extras that can be added to a policy include a full health check-up, dental and eye care, physiotherapy or prescription medicines. Whether MRI and CT scans are covered, and up to what amount, is set out in the policy terms.

Policies usually do not cover, or cover only to a limited extent:

• services during the waiting period (karenca) at the start of the policy
• illnesses and conditions that existed before the policy was taken out, if the terms list them as such
• cosmetic procedures, apart from exceptions that the policy explicitly lists
• treatment that the insurer does not consider medically necessary
• costs above the agreed limit

The procedure varies from one insurer to another, but the steps are usually similar:

• Call your insurer's medical contact centre. The number is on your insurance card or policy, and some companies also accept requests through an app or by email.
• Say that you would like a consultation at Maja Hospital in Niš and ask whether the hospital is in the network of providers for your policy.
• Ask whether you need a referral from your registered GP or a specialist's recommendation.
• Depending on the insurer, the appointment is booked by the insurer's contact centre or by you directly with the hospital. If you book it yourself, say that you are coming through insurance and with which company.
• Bring your insurance card or policy, your identity card, the referral if your insurer requires one, and your previous results.

When the facility is in your insurer's network and the service is covered, the insurer usually pays the costs, and you pay only the co-payment, if your policy includes one. If the facility is not in your insurer's network, you usually pay for the consultation yourself and then ask the insurer to pay you back (reimbursement), if your policy allows for it. With reimbursement, the insurer often refunds only part of the amount, according to the policy terms. If the service is not covered by your policy or the insurer has not approved it, you usually pay the costs yourself.

Check with your insurer and when booking whether Maja Hospital is in your insurance company's network of providers and how payment works.

For an operation and a hospital stay, the insurer usually requires prior approval. The steps usually follow this order:

• Consultation with the surgeon: the surgeon examines you and looks at your results. If an operation is needed, the surgeon proposes the type of procedure and gives you a report with the diagnosis and recommendation. The type of anaesthetic is decided by the anaesthetist, after the pre-operative assessment and in agreement with the surgeon and with you.
• Tests and assessments before the operation: depending on the procedure, your age and your health, you usually need laboratory tests and an ECG, and sometimes a scan or an assessment by another specialist. Before an operation under general or spinal anaesthetic, an assessment by an anaesthetist is usually also needed. Check with your insurer whether these tests and assessments are paid from the outpatient or the hospital part of your policy.
• Cost estimate: the insurer usually asks for the hospital's cost estimate (pro forma invoice) for the proposed procedure. Ask the hospital how to get the cost estimate and what it includes, for example the operation, anaesthesia, materials, days in hospital and follow-up appointments.
• Request to the insurer: you send the surgeon's report, your results and the cost estimate to the insurer, or the hospital sends them, depending on the insurer. The insurer's doctor may ask for further documents.
• Approval: if the procedure is covered, the insurer issues written approval stating the amount it covers. Some companies call this process authorisation.
• Date of the operation: you confirm the date once the approval has arrived. When you are admitted to hospital, bring the approval, your policy and your identity card.
• Price difference: if the price is higher than the approved amount or your policy includes a co-payment, you usually pay the difference yourself, directly to the hospital.

How long approval takes depends on the insurer and on whether your documents are complete. That is why you should send your request in good time, before agreeing a date for the operation.

With insurance for surgical procedures, the process is different: you usually pay for the operation yourself, and after it you send the insurer the documents needed to pay out the agreed benefit. Before the operation, ask your insurer which documents it requires.

In an emergency, do not wait for the insurer's approval. Sudden and severe abdominal pain, chest pain or difficulty breathing need emergency care: call an ambulance on 194 or go to the nearest emergency department. If you have a high temperature with shivering, contact a doctor without delay.

Before you book an operation, it is useful to get answers to a few questions from your insurer:

• Is Maja Hospital in Niš in the network of contracted providers for my policy?
• Does the insurer pay the hospital directly, or do I pay and then claim the money back (reimbursement)?
• Does my policy cover hospital treatment and operations, or only outpatient treatment?
• Is my operation covered, what is the limit for the operation and for days in hospital, and how much of it has already been used?
• If my policy pays a benefit according to a table of procedures, what is the amount for my operation?
• Is there a waiting period (karenca), and has it ended?
• Are illnesses that existed before the policy was taken out excluded from cover?
• Is there a co-payment, and how much is it?
• Do I need a referral from my registered GP, or is a specialist's report enough?
• Which documents need to be sent, and who sends them, me or the hospital?
• Are the anaesthetist's assessment, follow-up appointments after the operation and the histopathology report covered?
• What applies if the surgeon has to change the method during the operation, for example from keyhole (laparoscopic) to open surgery?

Ask for the answers in writing, for example by email. That way you have confirmation if anything about the costs is unclear later.

When booking a consultation or operation at the hospital:

• say that you are coming through voluntary insurance and name your insurance company
• ask for a cost estimate for the proposed procedure, once the surgeon has recommended it
• ask what the cost estimate includes: anaesthesia, materials, days in hospital and follow-up appointments
• ask whether the hospital sends the documents to the insurer or whether you do

In the general surgery price list, the surgeon's consultation, the surgeon's follow-up consultation, the surgeon's pre-operative assessment, a day in hospital, the first post-operative follow-up with the surgeon and stitch removal are listed as separate items. That is why you should ask the hospital which of them are included in the cost estimate, and check with your insurer which of them are included in the approved amount.

For admission, bring your identity card, your insurance card or policy, the insurer's written approval, all your results and a list of the medicines you take regularly, with their doses, especially blood thinners and medicines for diabetes. Do not stop taking any medicines on your own: your doctor will tell you whether any of them need to be stopped for a while before the operation.

To find out what else to pack, read the article “What to bring to hospital for an operation”, among the related articles at the bottom of the page.

Common reasons for turning down a request are that the policy does not cover the service, the limit has been used up, the waiting period (karenca) has not ended, the illness or condition existed before the policy was taken out, or the insurer does not consider the treatment medically necessary. In that case, ask for a written explanation. If you have further results or a doctor's opinion, you can submit them and ask for your case to be reassessed.

If you are not satisfied with the response, submit a written complaint to the insurer and keep proof that you submitted it. If you do not receive a response within the prescribed time limit, or you are not satisfied with it, you can contact the National Bank of Serbia, which supervises insurance companies.

You can also pay for the operation yourself. If your policy provides for reimbursement, after the procedure you send the insurer the invoice and your medical records. Before deciding to do this, check with your insurer whether it will pay you back and how much, because reimbursement without prior approval is not always possible.