1) Social Insurance Branches in Türkiye
In Türkiye, the social security system consists of four main insurance branches. The first is short-term insurance, including occupational accidents, diseases, sickness, and maternity insurance. The second branch in the system is long-term insurance, covering invalidity, old age, and death insurance. Although not directly regulated by the Social Insurance and Universal Health Insurance Law No. 5510, unemployment insurance constitutes the third pillar of the social security system and is governed by Law No. 4447 on Unemployment Insurance. This article focuses on the fourth pillar of the social security system: general health insurance.
2) Definition and Characteristics of General Health Insurance
General health insurance is defined as a system designed for all individuals—regardless of their financial capacity or personal preferences—to have equal, accessible, and effective access to healthcare services (Bostancı, 2008). The essence of general health insurance is to provide equal access to basic healthcare services for all members of society under the same conditions.
In Türkiye, as in many other countries, the general health insurance system is mandatory for all citizens (Kızılova, 2015). In other words, inclusion in general health insurance is not left to the preference or will of individuals in society, and therefore, although there are some exceptions, as a rule, everyone residing in the country is required to be included in the system.
Another issue that constitutes an obligation in the system is the requirement that everyone included in the system is obliged to pay general health insurance premiums. Thus, the services provided by the Turkish government within the scope of the system are financed by the premiums paid by the individuals included in the system. Apart from the collected premium payments, the government contributes to the system by paying premiums for individuals in need or with low income (Kızılova, 2015).
3) Scope of General Health Insurance
According to Article 2 of the Social Insurance and Universal Health Insurance Law No. 5510 (“the Law”), which entered into force on 1 June 2008, the Law covers real persons, all kinds of public and private legal entities, and other institutions and organizations without legal personality in terms of the persons who will benefit from general health insurance and the application of this Law.
The provisions of the Law specifically related to general health insurance are regulated between Articles 60 and 79, and some of those considered general health insured in Article 60 of the Law are briefly listed as follows:
- Employees working under a service contract and those in equivalent positions (4/a); individuals working in their own name and account without being bound by a service contract, village and quarter headmen (4/b); permanent employees, contracted employees, and those appointed as proxies from open positions in public administrations (4/c);
- Individuals with low income, heimatlos, and refugees;
- Those receiving pensions or allowances specified in the Law;
- Foreign nationals holding residence permits, individuals receiving unemployment benefits, and those who have won World, Olympic, or European Championships;
- Individuals who benefit from unemployment benefits pursuant to Law No. 4447 and from short work benefits pursuant to relevant laws.
Significantly, according to the first paragraph of Article 60 of the Law, to be considered general health insured for the above-mentioned groups, it is a prerequisite that the residence of the relevant persons must be in Türkiye (Ekin, 2012). Consequently, if a person does not reside in Türkiye although they are covered by the above-mentioned article, they will not be covered by the Law. Turkish citizens residing in Türkiye were compulsorily included in the scope of general health insurance on 1 January 2012 (Sosyal Güvenlik Kurumu).
While defining the scope of general health insurance, the Law also classifies the persons directly dependent on the general health insured and those not insured separately. Regarding the aforementioned issues, Article 3, subparagraph 10 of the Law defines the dependents of directly insured persons, and Article 62/2 stipulates that dependents will also benefit from general health insurance. On the other hand, the persons who are not considered insured and therefore cannot benefit from general health insurance are defined in Article 60/3 of the Law.
4) Commencement of General Health Insurance
The commencement of the general health insurance relationship differs according to the establishment of the insurance relationship, and this issue is regulated under two categories: the persons whose insurance will be registered ex officio by the Social Security Institution (“SSI”) and those for whom a registration notification must be submitted separately.
Individuals who are compulsorily insured within the scope of Article 4 of the Law are considered general health insurance holders as of the date their insurance is registered. Thus, no further notification is required to be made for such individuals, as well as voluntarily insured persons and the persons listed in the relevant subparagraphs of Article 61 of the Law (Kızılova, 2015).
However, individuals whose income is less than one-third of the minimum wage, recipients of old-age pensions under Law No. 2022, and those who receive pensions within the scope of other laws are required to notify the SSI to be considered as a beneficiary of general health insurance (Kızılova, 2015). It is worth noting that trainee lawyers also fall within the category requiring notification to the SSI. According to the supplementary clause of Article 61 of the Law, the general health insurance declaration of trainee lawyers is notified to the Institution by the Union of Turkish Bar Associations within one month from the date they start their internship.
5) Conditions for Benefiting from General Health Insurance
The conditions for benefiting from general health insurance are stipulated under the title of “Conditions for Benefiting from Healthcare Services” in Chapter Three of the Law, Articles 67 and following. The conditions for accessing health services and other entitlements under general health insurance are as follows:
- Except for individuals receiving income or pensions, the general rule is that the general health insurance holder must have paid premiums for at least 30 days within the year preceding the date of their application to the healthcare provider.
- A contribution fee payment is required for certain services specified in Article 68, such as physician and dentist examination in outpatient treatment, out-of-body prostheses and orthoses, and medicines provided in outpatient treatment.
- To prevent system congestion and unnecessary healthcare applications, insured individuals must comply with referral chains and healthcare service tiers as provided for in Article 70.
- Insured individuals must present their identity card when accessing healthcare services (Article 71).
Regarding the 30-day premium payment requirement, it is important to note that Article 67 of the Law exempts certain individuals (e.g., persons under 18, those requiring constant care, individuals in emergencies) from this requirement.
On the other hand, according to Article 67 of the Law, short-term, long-term, and general health insurance premium debts must not be outstanding, in addition to the requirement to pay 30 days of insurance premiums, for certain general health insured persons (such as village and quarter headmen, independent workers, voluntary insured persons, foreign citizens with a residence permit, etc.) listed in the relevant article of the Law.
6) Services and Rights Provided Under General Health Insurance
The Law stipulates the services that the general health insured and their dependents may and may not benefit from within the scope of insurance in Articles 63 and 64, respectively. The Law aims to ensure that individuals remain healthy through services financed and provided within the scope of the insurance, to restore their health in case of illness, and to address situations that are beyond their control, such as work accidents, medical interventions as a result of maternity, and incapacity for work (Kurt, 2020). Article 64 excludes non-essential services, such as elective cosmetic treatments and procedures that fall outside contemporary medical practices (Kurt, 2020).
Considering the provisions of Article 63, titled “Financed Healthcare Services and Its Term,” the services provided under general health insurance can be classified as follows:
- Preventive Health Services: These are services aimed at preventing illnesses and diagnosing diseases at an early stage.
- Curative Health Services: These services address individuals’ healthcare needs when they fall ill or require medical intervention.
- Overseas Treatment: Healthcare services provided to individuals sent abroad on temporary or permanent assignments or for illnesses that cannot be treated domestically.
- Rehabilitative Health Services: These services provide physical, mental, and social support to individuals in need.
- Other Covered Expenses: SSI may cover daily allowances and transportation costs for insured individuals, as deemed necessary.
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Ahmet Oğul AKSOY
Uçar Law & Consultancy Office
REFERENCES
Bostancı, D. Y. (2008). Sosyal Güvenlik Hukukunda Genel Sağlık Sigortası. Selçuk Üniversitesi Hukuk Fakültesi Dergisi, 145-173.
Ekin, A. (2012). Genel Sağlık Sigortasından Yararlanma Şartları ve Esasları. Türkiye Barolar Birliği Dergisi, 151-166.
Kızılova, A. T. (2015). Türkiye’de Genel Sağlık Sigortası: Gelişimi, Uygulanması ve Sorunları. Yüksek Lisans Tezi. Bursa: Uudağ Üniversitesi Sosyal Bilimler Enstitüsü Çalışma Ekonomisi ve Endüstri İlişkileri Anabilim Dalı.
Kurt, A. S. (2020). Türk Hukukunda Genel Sağlık Sigortası. Çankaya Üniversitesi Hukuk Fakültesi Dergisi, 2277-2305.
Sosyal Güvenlik Kurumu. (tarih yok). https://www.sgk.gov.tr/. Sosyal Güvenlik Kurumu Sitesi: https://www.sgk.gov.tr/Content/Post/742c02df-68e1-422c-a387-fa2e4326b015/Genel-Saglik-Sigortasi-nedir-2023-01-25-11-25-46 adresinden alındı
