Instructions for members
Members and activities
The operating area of the fund consists of the employers listed in the rules and the fund members employed by these. Each employee with a permanent employment becomes a member of the sickness fund after probationary period. For part-time employees, an average weekly working time of at least 21 hours is required in the employment contract. Employees with temporary employment will become fund members after probationary period of employment provided that the employment is intended to last at least six months. Another condition for the membership is that this employment is the main source of livelihood for the person.
The fund membership terminates when a fund member resigns or retires from the employment of an employer belonging to the operating area. Upon resignation, the member is not entitled to receive a refund for the membership fees paid.
The fund operates as an employees’ sickness fund governed by the Sickness Insurance Act and therefore it also pays its members all compensations based on the Sickness Insurance Act. This means that all your sickness insurance matters are processed through the fund.
Once you have received membership in the sickness fund, the Social Insurance Institution (Kela) will send to your home address a personal health insurance card, the Kela card, which bears an indication of the sickness fund membership. Upon termination of your membership, Kela will send you a new card.
Besides the benefits based on the Sickness Insurance Act, the sickness fund also provides certain additional benefits. The combined additional benefits and sickness insurance benefits are compensated at 80% for medical fees, examination and treatment fees, office fees of research and treatment institutions, polyclinic and hospital fees, appointment and annual fees of health centres, and dental care and spectacles, with the following limitations:
they are provided by Terveystalo Oy or public health care
For physiotherapy and physiotherapist examination, a maximum of €375 is compensated as additional benefit in a calendar year.
For the treatment by dentists, specialist dental technicians and dental hygienists, the combined maximum compensation as additional benefit is €375 in a calendar year.
A membership of 12 months is required for the compensation.
For the treatment and examinations by a psychologist, the maximum additional benefit is €850 in a calendar year.
The upper limit for the treatment day fee in hospital care is €34/day and the maximum number of compensable treatment days is 60 days in a calendar year.
For the expenses related to spectacles/contact lenses, a maximum of €250 is compensated within two calendar years. For this period, spectacles/contact lenses bought during the previous and current calendar year are taken into account. A membership of 12 months is required for the compensation.
These upper limits in EUR can be annually reviewed by the representative body.
For medications, clinical nutritional products and basic ointments prescribed by a doctor, the compensation is 80 % when compensation has also been received based on the Sickness Insurance Act. The compensation is calculated based on the price (cost or reference price) at which the compensation based on the Sickness Insurance Act has been calculated.
Additional benefit is not paid for fertility treatment and medications intended for impregnation.
Institutional and surgical theatre fees charged by the treatment and other institutions are not compensated.
The fund compensates only costs accrued during the membership. The costs are considered to arise at the time of providing the treatment. When considering the maximum annual amounts of compensations, the basis of compensation is determined according to the treatment time regardless of when the costs have been paid.
Dentists can be freely selected. In case of abuse, the board of the fund can limit this freedom of selection.
Employer is required to pay the sick pay. After the termination of sick pay the members will be paid the daily allowance based on the Sickness Insurance Act by Kela. The daily allowance based on the Sickness Insurance Act is taxable income from which the Kela deducts taxes. The employment pension contribution and the unemployment insurance contribution are deducted from the supplementary daily allowance.
In connection with pregnancy and child birth as well as for e care of a foster child Kela pays maternity and parental allowance for the mother and paternity and parental allowance for the father, according to the Sickness Insurance Act. You can send yous applications for these benefits to sickness fund. You can read more about parental allowances at Kela´s website.
Maternity, paternity and parental leave are based on the Contracts of Employment Act, and the parents are entitled to a nursing leave as specified by the Contracts of Employment Act. Additional benefits are not paid during the nursing leave.
In case of death, the sickness fund pays €1,700 to the beneficiaries as a funeral allowance.
Additional benefits and part of the administrative expenses of the fund are financed by the employers’ contributions and membership fees which are 1 % of the pay subject to the Prepayment Act, however, limited to €420 in a calendar year. The board of the fund can increase or decrease the membership fee for a fixed period on the basis of the rights defined in the rules.
According to the rules of the sickness fund, a member who becomes ill while absent from work because of a work stoppage or a temporary dismissal due to lack of work, or other unpaid off-duty, will not be paid additional benefits for medical treatment costs or supplementary daily allowance as defined in the rules of the fund.
Applying for compensation
Applications related to sickness allowances are delivered to the fund office via the payroll department. Applications for other benefits can be delivered directly to the fund office or via the payroll department.
Compensations are applied for mainly using original forms approved by the Social Insurance Institution and filled in by the treatment institution. A completed and signed application for compensation must be submitted enclosed with this form. When applying for several compensations simultaneously, one application is sufficient.
The sickness fund has made a contract for direct compensation with the pharmacy of the University of Eastern Finland, the pharmacy Joensuun Uusi Apteekki, the pharmacy Noljakan apteekki, the pharmacy Rauman III Keskus-Apteekki, the pharmacy Urpolan Apteekki, the pharmacy Vantaa V. Myyrmäki, the pharmacy Walkiakosken Apteekki, the pharmacy Yliopiston Apteekki, and the Association of Finnish Pharmacies. As the major part of Finnish pharmacies belong to the Association of Finnish Pharmacies, the contract applies to almost all pharmacies. Pharmacies included in the above-mentioned contract give a compensation for medications bought directly upon purchase and the member pays only the excess at the pharmacy.
Usually compensation is provided for the same medicament for an amount corresponding to the treatment of three months at most.
The Social Insurance Institution pays additional compensation for high medication costs if the costs exceed a certain limit in a calendar year. In such cases the person concerned will be informed of this.
For hospital fees, the invoice from the hospital is sufficient as an application for compensation. Treatment days and a specification of any other costs should be clearly indicated in the invoice.
The original receipt is sufficient as an application for compensation for spectacles/contact lenses provided that the name of the payer and a purchase specification are included in the receipt. In other cases, besides the receipt, a specification of the purchase costs of the spectacles/contact lenses provided by the optician is required.
For travel expenses, a separate application for travel expenses (SV 4) is required and it is necessary to simultaneously present a certificate or other description of the treatment object of the appointment. In case it has been necessary to use a special means of transport (e.g. a taxi or one’s own car) for travelling, a description of the necessity of this means of transport should be enclosed with the application (e.g. medical certificate of health condition or own description of transport connections) as well as a receipt of payment made.
Becoming ill and sickness allowances
When you become ill, immediately inform your closest manager
For sickness absence exceeding 10 days, a sickness allowance application form must be filled in. These forms are available at the work place, in the sickness fund office or Social Insurance Institution offices, and at the websites of the sickness fund or Social Insurance Institution.
To ensure that the sickness allowance is paid as fast as possible, the certificate given by the doctor or occupational health nurse and the sickness allowance application are to be delivered without delay to the payroll office via the manager. Different employers may have instructions of their own for the delivery of certificates, and these must be naturally followed.
The decision including a specification of benefits according to the Sickness Insurance Act is sent for information via the centralized postal service of the Social Insurance Institution.
Compensations for medical treatment are paid weekly. Sickness allowances payment dates you can see at Kela´s finacl act.
After the payment day, the sickness fund will deliver a
compensation calculation which shows the compensations paid by the fund.
Compensation for medical treatment costs should be applied for within 6 months from the payment of a charge or fee and the sickness allowance should be applied for within 2 months of the onset of getting sick.
A person unsatisfied with the decision on compensations
based on the Sickness Insurance Act can appeal to the social security appellate committee and thereafter to the Insurance Court. A solution recommendation can be requested for the additional benefits of the fund from the Financial Ombudsman Bureau. In case of complaints, more detailed instructions are available from the sickness fund.