Choice of healthcare provider

ZJCN does not have contracts with all care providers. If you wish to consult a non-contracted care provider, you need prior permission from ZJCN.  By non-contracted care provider we mean another care provider than the one you have been referred to by your GP, specialist or dentist. In this case, you can appeal to Article 10, paragraph 4 of the BES Healthcare Insurance Decree.  

Upon approval, you can receive either a full or partial reimbursement for the costs incurred for the specific treatment. Requests for reimbursement of non-contracted care must be submitted and approved before the treatment is started. Requests that are submitted after the treatment will be declared inadmissible and will not be processed.  ZJCN can also reject your request. Therefore, it is essential that you only undergo treatment when ZJCN has approved. If there are sufficient contracted care providers to choose from, who provide the same level of care and based on indicators such as quality and efficacy, ZJCN may reject the request.

You need to pay for the medical expenses first and then send the bill of the care provider to ZJCN then checks the bill and you will receive either a full or partial reimbursement of the costs. ZJCN does not pay the bill directly to the care provider. ZJCN uses quality indicators to monitor the quality and effectiveness of the care that is provided. Care is purchased based on these insights and selective purchases cannot be excluded.

Requests must be submitted by general practitioners or specialists. All requests must include the following documents:

  • medical statement of referrer (general practitioner or specialist)
  • quotation of non-contracted care provider with description of treatment and total costs
  • statement of approval signed by insured person

Incomplete requests will not be processed.

The legal framework 

The legal framework is formed by the BES Healthcare Insurance Decree and the BES Healthcare Insurance Claims Regulation. On this basis, insured persons can apply their entitlement to care in kind, insofar as that care can reasonably be offered on the islands. To that end, ZJCN concludes contracts with eligible care providers. 

The assumption is that the insured persons will turn to care providers that have entered into a contract with ZJCN (Article 10 paragraph 2 of the Decree). The Decree has also determined that it is possible for insured persons to turn to non-contracted care providers, both on and off the islands, pursuant to Article 10 paragraph 4 of the Decree.

Generally, if prior permission has been acquired from ZJCN, the insured person may turn to a non-contracted care provider and be entitled to full or partial reimbursement of the medical expenses incurred for this care.