1. When is the care provider entitled to the fee for the full cost of medical treatment (TÄKY)?
The insurance company can only pay the TÄKY fee after the decision has been made on whether the treatment has been given for compensable claim event and whether the medical care meets the compensability criteria.
The TÄKY fee cannot be paid unless the care provider submits to the insurer the records of the treatment appointments and the employer information. Regarding any further treatment, the care provider must also submit a treatment plan or treatment decision to the insurer by the given deadline.
2. How does the care provider know whether it is treating a claim event compensable under workers’ compensation insurance, for example whether the accident happened during the commute to work, or whether the medical care given is compensable?
The care provider does not have to investigate or decide such matters. The insurer will decide whether the incident is a compensable claim event and whether the medical care given is compensable. The care provider must submit the records of the treatment appointment to the insurer which, according to the injured person, underwrites the workers’ compensation policy provided by the employer. The insurer will investigate and decide whether the incident is an occupational accident or disease and whether the treatment is compensable.
3. What kind of information must the care provider seek before they can send the appointment records to the insurance company?
The care provider must have the details of the injured person’s employer and the insurance company underwriting the workers’ compensation policy provided by the employer.
If the care provider does not have the details of the insurance company underwriting the employer’s policy for the injured person, they must contact the Workers’ Compensation Center to obtain the correct information.
4. Where should the appointment records be sent if the patient says the employer has not provided an insurance policy?
If the incident is an occupational accident or disease, the appointment records are sent to the Workers’ Compensation Centre which processes claim events occurred during uninsured work. The Workers’ Compensation Center also processes claim events that occur during work commissioned by so-called small employers. The employer is not obliged to provide insurance if the wages and salaries paid, or agreed to be paid, by the employer for the work commissioned in a calendar year do not exceed 1,200 euros. This means that even though the employer does not have the insurance obligation in such cases, the employee will be paid compensation for the claim event by the Workers’ Compensation Center.
5. What kind of information must the care provider send to the insurer?
The care provider must send to the insurance company the appointment records for each treatment appointment and the details of the injured person’s employer.
In cases that require further treatment, the care provider must also send the injured person’s treatment plan, treatment decision, medical report or case history.
With regard to each treatment appointment, the necessary treatment and employer details can be sent with the plan for further treatment. There is no need to send two separate notifications.
6. What is the deadline for the care provider to send the information about the treatment appointment to the insurance company?
The appointment records and employer details concerning a one-off treatment appointment must be sent to the insurer without delay.
7. What is the care provider’s deadline for sending the plan for further treatment to the insurance company?
In cases requiring further treatment, the treatment plan is sent to the insurance company within four (4) working days from the date when the records concerning the plan must be entered into the patient documents. Under section 18(1) of the Decree of the Ministry of Social Affairs and Health on patient documents (298/2009), the patient document entries must be made within five (5) days from the date when the patient leaves the clinic or the service event is otherwise closed.
8. What is the purpose of the deadline of 4 + 5 days for sending the notification of further treatment?
The purpose of the notification procedure is to ensure that the insurance company receives, as quickly as possible, the information from the care provider that helps the insurer to decide whether a payment commitment should be issued to transfer the patient to a different care facility, in order to provide the treatment quicker.
If the care provider fails to fulfil their obligation to notify the insurer, the insurer will not be liable for paying the TÄKY fee for the treatment given.
The notification obligation is treatment-specific. Even if the care provider had neglected to notify the insurance company of the treatments given early in the injured person's care, the TÄKY fee can be paid for the later treatments included in the plan, if the insurer has been able to issue a payment commitment for them.
9. Is the notification of further treatment required for all care?
The notification does not have to be sent for:
- urgent medical treatment; and
- appointment at the clinic and minor medical interventions carried out during the appointment.
‘Urgent medical treatment’ refers to the assessment of the need for treatment during the first treatment appointment and treatment that cannot be postponed without substantial aggravation of the injury or illness. ‘Treatment that cannot be postponed’ excludes treatment that can be provided later without the postponement of the treatment causing substantial aggravation of the end result of the treatment.
The notification is not required for a one-off treatment appointment and the related minor medical intervention. ‘Minor medical intervention’ means an x-ray or ultrasonography examination or a similar low-cost treatment.
10. When a patient is sent to be examined by a specialist due to suspected occupational disease, who will submit the notification of further treatment to the insurance company?
The party sending the patient to a specialist also sends the notification to the insurance company. The Finnish Institute of Occupational Health (Helsinki) can notify the insurance company directly.
11. What should we do if the insurance company has not responded to the notification of further treatment?
The care provider continues to have the responsibility for care. An injured person seeking medical attention due to an occupational accident or disease must receive care on the same basis as other patients, and the care or treatment provision cannot be postponed until the insurance company issues a payment commitment.
The insurer may not have responded for a number of reasons:
- In practice, public sector care providers will not be issued with payment commitments if the care provision may continue. Only when the insurance company assigns the patient to a different care provider, the party requesting a payment commitment is informed.
- In addition, the insurance company may experience delays when it seeks information in order to decide whether the claim event is compensable. As long as compensability remains unclear, the insurance company cannot comment on the compensability of the treatment.
If the claim event is compensable as an occupational accident or disease and if the medical care given is compensable, the insurance company will pay the TÄKY fee to the care provider.
12. If the municipality has outsourced some or all of the health centre’s medical care services to a private service provider or issued the patient with a service voucher, can the private service provider invoice the insurance company directly?
No. Even in the outsourcing process, the municipality always has the notification obligation. However, the municipality and the outsourcing provider can agree that the provider notifies the insurer on behalf of the municipality. The municipality must inform the insurance company of the outsourced service and the service voucher when it sends the plan for further treatment to the insurance company.
The municipality must submit the notification in time for the insurance company to have a genuine opportunity to offer an alternative care provider before the treatment is given. In case of non-compliance, the ultimate responsibility lies with the municipality. The invoice must always be sent by the municipality or the joint municipal authority, as the insurance company does not have the right to pay the TÄKY fee to the outsourcing provider.
13. How are assistive devices compensated?
Medical rehabilitation aids are compensable as medical care by workers’ compensation insurance.
The medical rehabilitation aids are included in the treatment fee (TÄKY invoice) for which the invoice is sent, and no separate compensation is paid for them. If the patient receives the assistive devices free of charge, the care provider cannot invoice the insurance company for the patient fee.
14. If the patient’s payment ceiling has been reached, can the insurance company be charged for the client fee and the TÄKY fee?
Yes. In accordance with section 26(2) of the Act on client fees in social welfare and health care, client fees can be charged for the treatment compensable under the Workers’ Compensation Act, even when the payment amount exceeds the payment ceiling limit. Since the TÄKY fee is not connected to the client fee in any way, it will continue to be paid as normal.
However, the patient should not be charged for the client fee after the ceiling has been reached if it is unclear whether the treatment is necessary for the compensable occupational accident or disease.
15. What should be done with the TÄKY invoice if the insurance company will not settle it?
The patient cannot be charged for the TÄKY fee. The provisions of the Workers’ Compensation Act determine when the insurance company is liable for paying the TÄKY fee. The patient can only be charged for the client fee specified in the Client Fee Act.
If the claim event is not compensable as an occupational accident or disease, or if the medical care given is not compensable under the Workers’ Compensation Act, the insurance company will not be liable to pay the TÄKY fee. Nor will the insurer pay the TÄKY fee if the care provider has not fulfilled its notification obligation, i.e. submitted the appointment records, employer details and the treatment plan, if any.
In that case, the municipality will be invoiced for the actual cost of treatment.
16. Can the insurance company be charged for the overuse fees?
No. The overuse fees are penalties which municipalities must pay for failure to provide care. They do not fall under the remit of the system of workers’ compensation insurances.
17. Can the municipality/joint municipal authority appeal against the insurance company’s decision concerning the TÄKY payment?
The insurance company’s decision concerning the TÄKY fee can be appealed by the municipality/joint municipal authority in the following situations:
- TÄKY fee paid by the insurance company is smaller than the one specified in the municipality’s or joint municipal authority’s invoice or demand;
- Insurance company refuses to pay the TÄKY fee because the care provider has not fulfilled its notification obligations; or
- Municipality/joint municipal authority requests the insurance company’s decision on the TÄKY payment.
18. Can the municipality appeal against the insurance company’s decision on a claim?
Pursuant to the Workers’ Compensation Act, the municipality is not a party in a claim. The municipality cannot, therefore, appeal to the Employment Accidents Appeal Board against a decision on whether a claim event or medical care given is compensable under the Workers’ Compensation Act.
However, the municipality can appeal to the Employment Accidents Appeal Board against a decision concerning the TÄKY fee for care provided under the Workers’ Compensation Act. The municipality is entitled to appeal the decision if the amount of the TÄKY fee paid by the insurance company falls short of invoiced amount, or the TÄKY fee has not been paid because the municipality had not fulfilled its obligation to notify the insurer of the amount of fee or the commencement of care.
19. Can the TÄKY fee be collected by distraint?
No. The TÄKY fee is not the same as the client fee and is, therefore, not distrainable. Section 17 of the Client Fee Act on distrainability only applies to the client fees collected from the service user.
Insurance companies would like the care providers to set a longer term of payment for TÄKY invoices. As it may take a long time to obtain the documents that allow the insurer to make the decision on compensability, the care provider ends up sending unnecessary payment reminders.
20. How do the insurance companies manage TÄKY invoices if the claim has been instituted at the wrong company?
The insurance company will not return the invoices to the care provider. Instead, it sends them to the correct company and informs the care provider.
21. How should we proceed if the accident has happened during unpaid or voluntary work?
Since unpaid or voluntary work is not covered by workers’ compensation insurance, the TÄKY fee is not payable. The commissioner of the work may have provided an insurance for voluntary work, which is a voluntary insurance and therefore not covered by the TÄKY legislation.
In practice, it can be difficult to know whether the accident took place in an employment relationship or during voluntary work. In that case, the care provider must submit the information on the accident to the insurer which, according to the injured person, underwrites the workers’ compensation policy provided by the employer. The insurer will ascertain what type of work it is.
22. How will the care provider receive the TÄKY fee if a foreign person has had an occupational accident or is suspected of having an occupational disease?
We cannot give a complete answer to that question, but the following instructions will help to start the proceedings, and the insurer will investigate the matter further:
- In any situation, details of the patient’s employer should be clarified first.
- If the foreign person is employed by a Finnish company, the notification and the invoice will be sent to the employer’s insurance company.
- If the employer is a foreign company and the patient knows that it provides an insurance in Finland, the notification and the invoice will be sent to that insurer.
- If the employer is a foreign company and the patient does not know whether it provides an insurance in Finland, the notification and the invoice will be sent to TVK.
23. There are compensations that are provided in certain special acts but determined in accordance with the provisions of the Workers’ Compensation Act. Is the TÄKY fee payable if such special acts are applied?
Yes. Acts with reference provisions concerning the Workers’ Compensation Act include the acts such as:
- Act on compensation for injury or illness occurred in education-related conditions comparable to work;
- Act on accident compensation for persons in certain penal, welfare and nursing institutions;
- Rescue Act; and
- Sea Search and Rescue Act.
25. Does the TÄKY legislation apply to athletes?
Yes, if compensation is paid under the Act on athletes’ accidents and pension provision (laki urheilijan tapaturma- ja eläketurvasta 276/2009).
26. Does the TÄKY legislation apply to those serving non-military national service?
The service facility is liable to pay for the medical expenses arising from occupational accidents and diseases occurring during non-military national service. However, the persons undergoing non-military service are not covered by workers’ compensation insurance provided by the employer, i.e. the service facility. Instead, the service facility can take out a voluntary insurance against medical expenses. Since the insurance is not covered by the Workers’ Compensation act, the TÄKY fee is not payable.
However, if the medical care continues after the service has ended or the employer suspends the service due to a serious accident, the Treasury will take over the liability and the TÄKY fee will become payable.
27. A list of contact persons for TÄKY matters in the member insurance companies is available on TVK’s website. Can this list be used in case of road accidents?
The list can help with road accidents even though the persons on the list are the TÄKY specialists for workers’ compensation insurance. If they do not deal with road accidents, they can point you to the correct specialist in the company.
28. If a farmer has a small accident, but decides not to send the MATA claim report to Mela due to the loss of no-claims discount, will the municipality not be paid the TÄKY fee?
In accordance with the Farmers’ Accident Insurance Act, a claim can also be instituted if the care provider sends the appointment records and the treatment plan, if any, to Mela. If the information obtained in the matter shows that the claim event is compensable pursuant to the Farmers’ Accident Insurance Act, Mela will pay the TÄKY share to the municipality.
29. Can the municipality charge in the TÄKY invoice for the costs of foreign-language interpretation?
No. Costs of foreign-language interpretation are administrative costs arising from the provision of medical care. They are, therefore, not included in the compensable medical care under the Workers’ Compensation Act.
30. Can the insurance company include a reduction for contributory negligence in the TÄKY invoice?
Workers’ compensation insurance does not allow for a reduction for contributory negligence with regard to medical care costs. However, the motor liability insurance does allow for it. The municipality’s or joint municipal authority’s entitlement to the TÄKY fee is linked to the injured person’s entitlement to compensation. Therefore, if the compensation paid to the injured person includes a reduction for contributory negligence in the motor liability insurance, the reduction is also effected in the TÄKY fee. For further information, see a Decision of the Supreme Administrative Court (KHO:2013:149).
31. Can the care provider charge a fee for the notifications related to the TÄKY fee?
No. In accordance with the legislation, the insurance company has the right to receive the patient document entries related to the TÄKY fee free of charge, also when the notification is submitted using the E report.