Claims are handled by the Claims Unit of the Finnish Pharmaceutical Insurance Pool.
The claims handling process is made up of the following steps.
Recording of notice of injuryWhen a new notice of injury arrives at the Finnish Pharmaceutical Insurance Pool, the case is recorded and given a handling code.
Required documentationOnce the injury notice is recorded, the Finnish Pharmaceutical Insurance Pool acquires documentation extensive and thorough enough for handling the claim, on the basis of information recorded on the notice of injury. The Finnish Pharmaceutical Insurance Pool asks the treating institution direct for the required documents even if the notice of injury were accompanied by patient records. Enclosed in the Pool's request is a copy of the notice of injury, sent for information to the treating institution. Although the process is time-consuming, it is worth while to get as extensive a set of documents as possible for use as the basis of claims handling.
Statement from medical adviserOnce the required patient documentation is obtained, the case is assessed from the medical perspective. This usually translates into a specialist opinion from a medical adviser.
Pool's decisionOn receipt of the information and specialist opinions required for deciding on the case, the Finnish Pharmaceutical Insurance Pool issues a written decision on the case. In its decision the Pool takes a stand on whether the reported injury is compensable under the terms and conditions governing pharmaceutical injuries insurance. The ensuing acceptance or denial is sent to the claimant and to the policyholder, the Finnish Cooperative for the Indemnification of Medicine-Related Injuries. The decision is accompanied by appeal instructions.
Payment of compensationIn its acceptance, the Pool informs the claimant as to what kind of compensation is paid and attaches a claim form to this acceptance. The claimant is also given further details of next steps to be taken in the matter. Compensation for pain and suffering is paid at the time the notice of injury is accepted if only possible on the basis of the information available.
Anybody dissatisfied with the decision taken by the Finnish Pharmaceutical Insurance Pool on a claim for compensation may seek redress. Appeal instructions are attached to the Pool's decision.
Request for adjustmentThe claimant may ask the Finnish Pharmaceutical Insurance Pool to rethink its decision in cases where new information significant from the compensability perspective has emerged. The claimant's request should contain such new information, if possible, or at least an indication where such information is available.
AppealThe claimant may also ask the Finnish Pharmaceutical Injuries Board to issue a statement. The deadline for this request is six months of the date that the claimant became aware of the Pool's decision and of the six-month deadline.
A dispute between the Finnish Pharmaceutical Insurance Pool and the claimant may also be settled by agreement between the parties as is provided in the Arbitration Act (967/92).
Instead of choosing arbitration, the claimant may take legal action against the Finnish Pharmaceutical Insurance Pool in the Helsinki City Court or in the local court of his or her domicile. The case is to be taken to court, whether arbitration or local court, within three years of the date that the injured became aware of the Pool's decision and of this deadline.