Patient Insurance will only cover the extra costs and losses incurred by the patient injury. Costs and losses that would have been incurred regardless of the patient injury are not covered by the insurance. Consequently, compensation cannot be awarded for medical expenses incurred by the original treatment or examination of the patient's illness or injury. Therefore, when assessing the amount of compensation payable, the costs and financial losses due to the pre-existing illness or injury and those incurred by the patient injury must always be separated.
Compensation payable under Patient Insurance is determined by applying the provisions contained in the Tort Liability Act and the guidelines issued by the Traffic Accident Board. The decision policy of the Patient Injuries Board will also be taken into account in the compensation. As a rule, costs and losses arising from the injury will be compensated for in full. However, the injured party is also expected to prevent any subsequent loss whenever possible. The costs incurred must be necessary with regard to the treatment of patient injuries.
Further information on compensation criteria is available on the website of the Traffic Accident Board (in Finnish and Swedish).
Patient insurance is 'secondary' to most of the other statutory insurances and benefits. The patient will therefore receive compensation only for that part of the costs and losses due to the patient injury that is not covered by other statutory benefits and insurance provisions.
Patient Insurance covers the extra expenses of medical care needed for the injury. Compensable costs may include, for example, costs for extra hospital treatment and out-patient treatment, doctor's appointments, home health care, laboratory examinations, medicines, physical therapy and rehabilitation. If the body granting healthcare aid devices considers such a device necessary, aid device costs may also be compensated for.
Injuries that occurred in connection with public health care are compensated for according to the rates charged by the public sector, unless there are exceptional medical grounds for using private medical services. Such exceptional circumstances may exist, for example, if the treatment is not available in the public sector.
Travel expenses incurred by additional treatment may also be compensated for as other necessary costs incurred by the injury. In addition, following compensation may be paid:
Acute pain and suffering and other inconvenience sustained by the patient immediately after the injury will be compensated for as temporary incapacity.
The amount of compensation is determined by the degree of severity of the illness or injury, the duration of the recovery time, procedures, and the need for hospitalization. If the pain becomes chronic, it will be taken into account when determining the compensation for permanent incapacity.
Additional permanent functional incapacity (disability) resulting from a patient injury will be determined by using the classification of permanent disabilities. Consequently, compensation will not be paid for a permanent incapacity caused by the originally treated illness.
Depending on the time of receiving the injury, the incapacity will be determined on the basis of either the Decision of the Ministry of Social Affairs and Health (1012/1986) or the Decree (1649/2009). In the classification of permanent disabilities, the functional incapacity has been divided in incapacity categories 1–20.
Permanent incapacity is estimated based on available medical reports. Compensation amount is affected by the nature of injury and the age of the injured party.
If the patient injury causes permanent impairment to a person's appearance, in other words cosmetic incapacity, such as a scar, it will be compensated for by paying damages for cosmetic incapacity. However, compensation will not be paid for cosmetic incapacity caused by the treatment of the original treatment.
When assessing the amount of compensation, the following criteria will be taken into account: the extent, form, colour, location and visibility of the scar. The age of the injured party is another factor that affects the amount of compensation payable.
If an employee or a self-employed person loses income owing to occupational disability caused by the patient injury, the loss may be compensated for under patient insurance Compensation can be paid for partial occupational disability, too. For example, if the injured party is capable of working part-time after injury, they will be paid the difference between full-time and part-time employment so that their income level will not decrease.
When assessing a person's working capacity, the remaining working capacity and opportunities for occupational rehabilitation will be taken into account. The effects of the possible pre-existing illness or injury are also considered. In addition, the patient is obliged to find out about their possibilities to enhance their working capacity by medical or occupational rehabilitation.
If the patient's working capacity has been reduced by the patient injury, the subsequent loss of income will be compensated for according to the actual loss. Consequently, the amount of compensation will be calculated with reference to the estimated income the injured party would have received had the patient injury not occurred.
If the other benefits paid on the basis of other laws do not cover the loss of income in its entirety, the remaining part will be compensated for from the patient insurance. When calculating the compensation, daily allowances and pensions received under other statutory insurance schemes, such as Motor Liability Insurance Act (Liikennevakuutuslaki 279/1959), Worker's Compensation Insurance Act (Tapaturmavakuutuslaki 608/1948), various acts of employee's pensions and National Pensions Act (Kansaneläkelaki 347/1956) will be deducted.
Loss of income paid from patient insurance is subject to tax.
Certain family members of the injured party and others who are especially close to the injured party may have the right to receive reasonable compensation for necessary expenses and loss of income as a result of taking care of the injured party during a period of acute convalescence. Family members are entitled compensation for injuries that occurred in connection with treatment given on 1 January 2006 or after.
In cases where the injury leads to the loss of life, funeral expenses and other related costs can be covered to an equitable amount. Insurance will cover costs relating to, for example, the burial place, coffin, gravestone, funeral ceremony, flowers, obituary notice, and mourning clothes. Funeral expenses will be paid to the estate or the person who paid for the funeral.
Compensation to cover funeral costs received under other insurance provisions may be deducted from the patient insurance compensation. The costs arising from the estate inventory are not covered, since such costs are not considered compensable according to established legal practice as they are not related to actual funeral costs.
In cases where there is a loss of life, necessary maintenance may be granted to those entitled to this compensation. People entitled to this compensation are the husband or wife and under-age children and, in some cases, children under 21 who are studying. Compensation may also be payable to persons who received de facto maintenance from the deceased.
Compensation is payable under patient insurance to the extent that other sources of income and compensation payable under other statutory schemes do not guarantee sufficient maintenance to the applicant.