Seven compensation criteria are listed in the Patient Injuries Act: treatment injury, infection injury, accident injury, equipment-related injury, injury arising from damage to premises or treatment equipment, injury due to incorrect delivery of pharmaceuticals, and unreasonable injury. A bodily injury may be compensable under Patient Insurance, when any of the compensation criteria referred to in the Act is met.
A treatment injury is the most typical compensable injury. A compensable treatment injury is a bodily injury which was caused by an examination, treatment or other similar action performed on the patient, or the failure to do so. The term "other similar action" refers to, for example, a vaccination and blood or organ donation. An injury caused by an erroneous prescription or dosage of drugs may also be compensated for as a treatment injury.
A prerequisite for compensation is that an experienced medical professional could have performed a different procedure in the examination or treatment situation in question, thereby avoiding the injury. Consequently, a treatment injury may be, for example, a post-operative complication, such as a nerve injury or a delay in diagnosis, which could have been avoided by an experienced professional.
The content and level of proficiency required by experienced healthcare personnel varies. For example, a general practitioner at a healthcare centre and a specialist at a university hospital have different requirements.
The majority of rejected claims are due to the fact that regardless of appropriate treatment, the injury could not have been entirely avoided. It is not always possible to achieve satisfactory treatment results, for example, due to the serious nature of an illness or trauma. Such consequences are not compensated for if the procedures were in line with the standards required of an experienced medical professional, and yet the injury could not be avoided. Injuries may, however, be compensated for as an unreasonable injury in cases where the injury is caused by a severe and sudden consequence of the treatment.
Even if a sufficient level of competence is not always achieved by a medical professional, this does not necessarily mean that a patient will incur a compensable bodily injury as a result. For example, a correct diagnosis is occasionally reached only after some delay, even though proper examinations could have enabled an earlier diagnosis. The injury is not compensable if the delay has not affected the content, the prognosis or the end result of the treatment.
Infection injuries refer to infections, which the patient has probably contracted in connection with an examination, treatment or other similar action. Unlike treatment injuries, infection injuries can be compensated for without determining whether the infection could have been avoided by acting differently. All treatment procedures carry some risk of infections and they cannot usually be avoided. In practice, this means that ordinary, superficial, fast healing infections will always fall outside the scope of compensation.
Consequently, all injuries caused by infection are not compensated. The compensability of the injury is decided based on a separate 'infection tolerance evaluation'. This evaluation takes into account the infection risk in each individual case. The infection risk comprises the risk related to the procedure and possible pre-existing illnesses, injuries or medication of the patient that may contribute to the elevated risk. Moreover, the evaluation will take into account the severity of the injury caused by the infection, the nature of the illness or injury being treated as well as the overall health of the patient.
The patient is expected to tolerate more serious consequences of an infection the more serious the original illness or injury was that resulted in the infection and the higher the risk of infection. Yet, despite the increased risk, an injury caused by an infection may be compensable if it is rare and sudden.
The term accidental injury refers to various sudden, unexpected and external events occurring without the will of the injured party and causing injury in connection with a medical examination or treatment. Accidents that occurred during patient transport by ambulance are classified as accidental injuries, unless the injury is compensable under motor liability insurance.
The patient insurance only covers accident risks directly related to the procedures but not accident risks that are part of ordinary life. For example, a bodily injury received by a patient falling off the examination table may be a compensable accidental injury, whereas an injury that results from falling down in a hospital corridor is not an accident that is connected to treatment. However, it may be compensable as a treatment injury, if the proper patient monitoring or assistance was neglected even though it could have been provided, considering the available resources.
Compensation is paid for an equipment-related bodily injury if the injury was caused to the patient by a defect in the equipment or device that was used for the examination, treatment, or other similar action. This equipment or devices include surgical instruments, patient monitoring equipment and examination tables. A defect refers to any situation where a piece of equipment does not function the way it should and it is not caused by the actions of the medical staff.
Internal devices, permanently installed in the patient, such as joint endoprostheses or pacemakers, do not qualify for compensation if defective. Compensation for injuries caused by internal devices can be applied for under the Tort Liability Act or the Product Liability Act.
Injury to the patient arising from damage to premises or treatment equipment may be compensated for as a patient injury. This kind of injury may be caused by, for example, a fire. To qualify for compensation, this injury must have been sudden by nature.
Patient Insurance covers bodily injuries caused by prescription pharmaceuticals if these drugs were delivered by the pharmacist contrary to the prescription or regulations governing the delivery of pharmaceuticals. In the most common cases, the pharmaceutical delivered or the dosage or user instructions differ from what was originally prescribed.
This provision refers to the incorrect delivery of prescription pharmaceuticals from the pharmacist. In other cases injuries related pharmaceuticals being administered to the patient in conjunction with an examination or treatment are processed under the section on dealing with treatment injuries. In this case, compensation under patient insurance requires that the mistake was made in prescribing or dosing the medicine, judged against the standards of an experienced medical professional.
Side effects from pharmaceuticals which were appropriately prescribed and dosed are not compensated for under Patient Insurance. Such consequences may be compensable under voluntary Pharmaceutical Injuries Insurance provided by Finnish Mutual Insurance Company for Pharmaceutical Injury Indemnities.
If in conjunction with appropriate examination, treatment or other corresponding processing a severe injury which is materially disproportionate with the initial situation, it may be compensated for based on the provision related to unreasonable injury regardless of whether the injury could have been prevented by acting in a different manner.
The compensability will be decided on the basis of unreasonableness evaluation. The evaluation of an injury as unreasonable provides justifiable grounds for compensation only in cases where the patient has been caused a permanent severe illness, injury, or loss of life. An illness or injury is considered to be severe if it falls at least into Classes 7 or 8 in the Ministry of Social Affairs and Health's classification of injuries.
When evaluating the possible unreasonableness of an injury, the following factors will be taken into consideration:
An injury might be compensable as unreasonable if there is considerable disproportion between the consequence and the patient's illness or injury originally treated and his or her overall health. The greater the disproportion and the greater the negative effect on the patient's health caused, the more evident it seems that the injury might be unreasonable.
For example, a severely debilitating permanent neuropathic pain caused by a routine procedure might be compensable based on the unreasonableness provision. Continuation of a pre-existing illness or its turn to worse will not be taken into account, since the unreasonable injury must be caused by the treatment given.
Even severe complications are not compensated for if the risks were foreseeable by medical experts, or, if left untreated, the illness or injury could lead to the death or serious disablement of the patient.
Not all consequences of medical treatment and health care are compensated for, only the bodily injuries that fulfil the conditions prescribed in the Patient Injuries Act. Consequently, the following will not be compensated: