Case I A Ca 1266/05

Since 1999, plaintiff Teaching Hospital and defendant National Healthcare Fund entered into contracts that committed the National Healthcare Fund to finance the obstetric pathology services provided by Teaching Hospital. The contracts between the plaintiff and defendant contained a maximum annual amount that the National Healthcare Fund would finance for the subsequent year, however due to the difficulty of determining the exact amount of services which Teaching Hospital would provide in the year, such limit was determined by estimations. Historically, the National Healthcare Fund had attempted to reimburse Teaching Hospital for services provided which exceeded the limit set forth in the contract.

In 2003, the Health Fund organization was transformed into the National Healthcare Fund. At this time, the funding of the organization decreased to only cover the previously contracted benefits. Later in 2003, the National Healthcare Fund ceased its activity due to lack of resources. Without any funding, the National Healthcare Fund was unable to pay Teaching Hospital for services provided over the previously agreed upon limit.

Teaching Hospital submitted an invoice to National Healthcare Fund for PLN 1,372,130. This amount constituted the cost of providing obstetric pathologies to patients in emergency cases past the predetermined limit. The defendant refused to pay for these services because they exceeded the limits set forth in the contracts.

Teaching Hospital sued National Healthcare Fund for payment in the Circuit Court of Poznań. The Circuit Court found the request by Teaching Hospital unjustified. Teaching Hospital appealed this judgment.

The Appellate Court reversed the judgment of the Circuit Court.

The Court held that Art. 68(3) of the Constitution, containing a right to the protection of health and equal access to publicly funded healthcare benefits, was not applicable because the article solely expressed political principles and could not be a source of individual direct claims.

However, the Court determined that, Art. 7 of the Act on Healthcare Institutions (setting forth the requirement to provide insured persons who approach health facilities with healthcare benefits) and Art. 30 of the Act on Practicing as a Physician  (imposing a duty on physicians to give medical assistance) did entitle the plaintiff to payment. These articles required healthcare institutions and physicians to provide medical care in all life threatening cases. Since such services were ordinarily covered by publicly-funded health insurance, a prior Supreme Court decision had found that plaintiffs were entitled to payment for services provided under these articles and that it would be unjustified to saddle healthcare providers with the cost of these services. Based on this prior Supreme Court ruling, the Court held that the defendant, as the disposer of public funds for life-saving care, was obligated to provide for the cost of these services provided by the plaintiff and insufficient funds was not a sufficient excuse to negate this duty.

“However, the opinion of the Supreme Court is that, pursuant to Art. 56 of the Civil Code, a legal transaction produces not only the effects expressed by the transaction itself, but also those provided for by the law and, pursuant to the provisions of the law, the plaintiff was charged with the duty of providing healthcare benefits in each life-threatening situation, not only within the contracted limits. The Foregoing makes it possible for the plaintiff to press claims for costs incurred.” [Page 4]

“The Supreme Court in all of its judgments to date regarding publicly funded healthcare benefits, both quoted by the parties, and in the aforementioned judgment of 15 December 2005, which is attached to the records of the case, indicated the binding power of contracts entered into by healthcare institutions with the defendant or with its antecedent. However, in its judgment of 15 December 2005, the Supreme Court found that the plaintiff was entitled to claims for benefits provided in circumstances defined under Art. 7 of the Act on Healthcare Institutions and under Art. 30 of the Act on Practicing as a Physician, even though these benefits exceeded the contracted limits. This is because, as a principle, benefits provided to persons covered by the public health insurance are financed from public funds, that is previously by Health Funds and currently by the National Healthcare Fund. Simultaneously, there are no grounds for charging healthcare institutions with these costs. This is the conclusion that would arise from accepting the possibility of quoting by the defendant and by his antecedent of Art. 4(3) of the Act on Universal Health Insurance and of the argument of insufficient funds. Such a conclusion would be irreconcilable with Art. 30 of the Act on Practicing as a Physician pursuant to Art. 68(2) of the Constitution. An interpretation of Art. 7 of the Act on Healthcare Institutions and of Art. 30 of the Act on Practicing as a Physician which is consistent with Art. 68(2) of the Constitution leads to the conclusion that life-saving treatments should be financed from public funds, the disposer of which within the scope of healthcare benefits is currently the defendant.” [Page 4]