Terug naar Encyclopedie
Verzekeringsrecht

Health Insurance: Entitlements and Rights

In the historic city of Leiden, Netherlands, where academic vibrancy meets everyday resilience, residents rely on zorgverzekering (health insurance) as a cornerstone of financial security amid rising

4 min leestijd

In the historic city of Leiden, Netherlands, where academic vibrancy meets everyday resilience, residents rely on zorgverzekering (health insurance) as a cornerstone of financial security amid rising medical needs. This article delves into "Ziektekostenverzekering: aanspraken en rechten," illuminating your entitlements—from coverage for treatments and medications to appeals against denials under Dutch law. Tailored for Leiden locals, it empowers you to navigate the system with confidence and claim what''s rightfully yours.

Health Insurance: Entitlements and Rights

Health Insurance: Entitlements and Rights

Introduction

Everyone in the Netherlands is required to take out basic health insurance for healthcare costs. This health insurance covers essential medical care but has strict rules on what is and is not reimbursed. As a citizen, you have specific entitlements and rights, such as the right to adequate reimbursement for care and the ability to file an objection to unjustified rejections. This article explains what you can expect, what rights you have, and what steps you can take in case of problems. This way, you know exactly where you stand and how to defend your rights.

What does the basic insurance cover?

The basic insurance, established by the government, reimburses standard care such as GP visits, hospital admissions, medicines from the Medicines Reimbursement System (GVS), maternity care, and certain medical devices such as hearing aids or walkers.

Important exclusions:
  • Deductible: For 2024, this amounts to €385 (unless you have chosen a lower voluntary deductible). You pay this yourself for care from the basic insurance, except for GP care, maternity care, and some others.
  • Co-payment: For specific care such as hearing aids or district nursing, you pay a fixed amount in addition to the deductible.
  • Supplementary insurance: For dentist, physiotherapy, or glasses, you often need supplementary insurance, which is not mandatory.

Always check your policy conditions and the website of the Netherlands Healthcare Institute for the current coverage.

Your entitlements to care and reimbursement

You are entitled to care that is ''medically necessary'' and meets the standards of ''good care'' according to the state of the art. This means:

  • No discrimination: Insurers may not refuse care based on age, gender, or health status.
  • Non-contracted care: You can go to any care provider that has a contract with your insurer (approximately 90-100% of care). With non-contracted providers, you will be reimbursed a maximum of 75-100%, depending on the type of care.
  • Continuity: If you move or change insurers, care may not simply be stopped.

For claims, you are entitled to a clear specification and a reasonable processing time (usually within 2 weeks).

Your rights in disputes

If your care is not (fully) reimbursed, you have strong rights:

  • Information obligation: Insurers must explain in writing why something is not reimbursed.
  • Objection and appeal: You can file a free objection and, if necessary, go to court.
  • Victim scheme: In case of injury due to medical errors, you can claim reimbursement under the Quality, Complaints and Disputes in Healthcare Act (Wkkgz).
Specific situations:
  • Chronic illness: Entitlement to chronic wound care or dietary advice.
  • Children up to 18 years: Fully covered without deductible.
  • Urgency: In case of emergency care, immediate assistance must be provided, with full reimbursement afterwards.

Practical steps: What do you do in case of problems?

Follow these steps to claim your rights:

1. Check your policy and claim: Log in to your insurer''s app or website. Request an overview of outstanding claims. Compare with the invoice from the care provider.

2. Request explanation: Call or write to your insurer within 180 days after the care. Request a detailed explanation if something is not reimbursed. Keep all correspondence.

3. File an objection: Within 6 weeks of the decision, send an objection letter by mail or email. Use a model letter from the website of the Authority for Consumers & Markets (ACM) or Zorgwijzer. Include: your policy number, date of care, reason for objection, and evidence (invoices, medical statements). The insurer must respond within 6 weeks (extendable by 6 weeks).

4. Seek help: Contact your care provider for authorization or a second opinion. Join a patient organization such as Patiëntenfederatie Nederland for free advice.

5. File an appeal: In case of rejection, within 6 weeks to the disputes committee via SKGZ.nl (cost €60, refunded if you win) or directly to the district court (free with legal assistance).

6. Switch insurers: Do this before 1 January via Zorgverzekeringslijn.nl. You retain rights to ongoing care.

Tip: Keep a file with all invoices, letters, and dates. This speeds up procedures.

Conclusion

Your health insurance provides solid basic protection, but know your entitlements and rights to avoid surprises. By acting proactively – such as filing a timely objection – you can save a lot of money and stress. If in doubt: consult free helplines such as the Zorgverzekeringslijn (1200) or