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Strict oversight coming for SGK payments: The era of 'pay first, get reimbursed later' has ended

The Court of Cassation has ruled that medical and scientific documentation must be provided for the reimbursement of 'smart drugs' used in cancer treatment. A doctor's report will no longer be sufficient on its own; specific reports, clinical evidence, and genetic compatibility requirements will be mandatory for every patient.

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A new era has begun for lawsuits filed against the Social Security Institution (SGK) regarding reimbursement for smart drugs, which have frequently been brought to the agenda by cancer patients in recent years. According to SGK expert İsa Karakaş, 'The era of saying, "I will pay for the smart drug myself, and then I will win the court case based on the report I receive regarding the treatment and get my money back anyway," has ended.' This development makes it mandatory to scientifically and medically document the benefit of the requested drug and its suitability for the patient before going to court.

COURT OF CASSATION MANDATES SCIENTIFIC CRITERIA

In a lawsuit filed by a patient against the SGK for a smart drug containing the active ingredient Avelumab, the first-instance and appellate courts had ruled for payment, concluding that doctor's reports alone were sufficient. However, the 10th Civil Chamber of the Court of Cassation overturned this decision, pointing out that the file had been insufficiently examined. The court underscored that the SGK must have a much more comprehensive and scientific verification process regarding drug payments.

In the reasoning for the decision, the court cited the European Court of Human Rights, emphasizing that the state must maintain a fair balance with its financial resources when providing healthcare services: Every healthcare service should ideally be free, but the sustainability of the public budget must be ensured. If every drug were to be covered by the SGK without any conditions, the budget balance could be disrupted, and the rights of other patients could be compromised.

GOLDEN CRITERIA ESTABLISHED

Under the new framework introduced by the Court of Cassation, the following conditions will be required for the SGK to make a payment for a drug:

  • The reliability and efficacy of the drug must be registered through clinical trials,
  • The suitability of the drug to the patient's genetic structure must be demonstrated through medical tests,
  • Documenting through a medical board report that the medication provides continuous, rather than temporary, benefits,
  • Proving that the medications currently covered by the SGK are insufficient for the patient's treatment.

HOW HAS THE PROCESS CHANGED FOR INSURED INDIVIDUALS?

The era of 'every new drug is covered for every patient' is now closing. Before filing lawsuits or payment applications, insured individuals must scientifically demonstrate that the medication they intend to use is suitable for their specific disease profile and genetic makeup. This signifies a strict control mechanism, particularly for access to experimental or not-yet-widespread treatments.

Furthermore, this paves the way for more efficient use of public resources; payments for drugs lacking scientific basis or proof will no longer be able to strain the SGK budget.

This decision by the Court of Cassation has provided a clear roadmap for thousands of patients. The framework of the ruling was defined with the statement: 'Yes, the right to life is sacred; however, no treatment that is not supported by medical necessity and scientific data can be imposed on the public (SGK) budget.'