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A dissatisfied client filed a complaint with the National Ombudsman after Bonaire Health Insurance Office (B-ZVK) rejected his application.
The client travelled to Europe to undergo two operations in the Netherlands, but his medical problems persisted. As a result, he went back to see his specialist. The client’s complaint is about B-ZVK’s decision not to reimburse him for this follow-up examination. Before he had his first operation, the client contacted B-ZVK to make sure that his medical expenses would be reimbursed. B-ZVK gave its guarantee and reimbursed the client for the cost of the operations. But as the follow-up examination was not covered by this guarantee, B-ZVK required the client to reapply. The client’s doctor submitted this application, but B-ZVK turned it down because the client had not enclosed a quotation with his new application. In other words, B-ZVK refused to reimburse the client for the specialist’s bill. The man disagreed with this decision and filed a complaint, stating that he did not supply a quotation because the specialist did not yet know what was wrong with him. He also believed it was only reasonable that the examination should be reimbursed. B-ZVK maintained its position and explained why it was refusing to reimburse the client for the cost of the bill.
The National Ombudsman concludes that B-ZVK did not give its client the opportunity to complete his application. The National Ombudsman finds that B-ZVK acted contrary to the requirement of fair play by not giving its client the opportunity to complete the application. The National Ombudsman therefore finds the complaint to be well-founded.
The National Ombudsman is pleased to hear that B-ZVK now plans to reimburse the complainant after all. With the benefit of hindsight, B-ZVK acknowledged that the specific situation could be treated as a case of unforeseen circumstances. The National Ombudsman is also pleased to hear that, in future, B-ZVK intends to place greater emphasis in its complaints procedure on communication and hearing citizens’ cases.
Client complains that B-ZVK refused to reimburse his bill for a medical examination by a specialist. He also complains that he was not given a further opportunity to contest B-ZVK’s position.
Decision: The complaint is well-founded.